CareFirst Coverage Basics
Overview of how CareFirst covers rehab.
Types of CareFirst Plans and Network Rules
Breaks down PPO, HMO, EPO, and POS plans, highlighting differences in out-of-network coverage, referral requirements, and flexibility when choosing rehab.
Costs & What You’ll Pay
Breaks down deductibles, coinsurance, and why in-network care is usually the most affordable option.
How to Choose Rehab with CareFirst
Step-by-step guidance to find the right level of care, confirm your plan, and verify benefits with facilities.
Finding the right treatment can be overwhelming, but your CareFirst BlueCross BlueShield insurance can make it easier to choose care. Most CareFirst plans cover life-saving addiction services. This page will help you understand how CareFirst coverage typically works so you can maximize your benefits and minimize your costs.
Note: Blue Cross Blue Shield is not one single insurance company. It’s a national association of independent, locally operated Blue plans, so your coverage depends on your local BCBS company, your plan type, and your specific benefits. Some BCBS plans also use a separate behavioral health partner or administrator to manage coverage.
Most CareFirst plans cover addiction treatment, but benefits vary widely. Knowing the type of plan you have will help you narrow your search for the right type of care. Coverage may come through an employer, the ACA marketplace, Medicare Advantage, or Medicaid, and most CareFirst plans use one of the network types below. Network types determine which providers you can use and if you need a referral for specific services.
High-Deductible Plans (HDHP): Some CareFirst plans are high-deductible plans. HDHPs are not a separate plan type, and the network rules for PPOs, HMOs, and POS noted above still apply to HDHPs. HDHP plans generally impact how costs are handled and when you pay for care. Many HDHPs are often also paired with a Health Savings Account (HSA). With these plans, you could potentially pay more out of pocket before your coverage begins, but an HSA can help cover costs until you meet your deductible and once the deductible is met, your plan could cover a larger portion of treatment costs.
The way you purchased your CareFirst plan can also impact your coverage. See details below on State Exchange (Marketplace), Medicare Advantage, and Medicaid plans and the changes to coverage based on which program you purchased your CareFirst plan through.
You can get insurance coverage through the ACA marketplace in parts of Maryland, Washington, D.C., and Northern Virginia. Plans purchased through the marketplace use the same network types (HMO, PPO, or POS), but they often have some variations in coverage.
Some people receive insurance through CareFirst Medicare Advantage PPO plans, but coverage rules can be different for these plans versus an employer-sponsored plan.
For people with limited income, Medicaid plans are a great route to receive health insurance coverage. Coverage rules for Medicaid plans vary widely by state.
CareFirst will review your specific care needs and your plan to make insurance coverage decisions like it would for other medical needs, such as a heart condition or diabetes. Because of federal parity law, coverage for addiction treatment cannot be more restrictive than coverage for other medical needs.
Coverage through CareFirst varies by the type of plan you have and the state you reside in. Two people with CareFirst may have very different benefits, even for the same treatment program.
The following aspects of coverage usually vary by plan and state:
Prior authorization needs
How long treatment is approved for
Differences in coverage for levels of care
Out-of-pocket maximums that put a cap on how much you pay
Learn more about how insurance and out-of-pocket costs usually work for rehab.
Choosing an in-network treatment facility is usually the best way to limit any out-of-pocket costs. We’ve provided the following illustrative example to show how CareFirst could potentially handle coverage for a hypothetical residential treatment program using a PPO plan.
Note: This example is hypothetical and actual costs depend on your specific plan and provider. Actual CareFirst plans may use copays, different coinsurance rates, or vary by service.
If you’re trying to pick the best treatment for you and you have CareFirst coverage, the following steps can help you narrow your care options and make a final decision.
CareFirst will typically cover treatment based on medical necessity. Before you try to decide on a specific facility choice, it will help to understand what level of care you actually need. To help you determine the level of care that is best for you, you can speak to a medical professional.
Levels of care include:
Your specific CareFirst plan will greatly impact the level of coverage you’ll receive for different facilities. You can review your insurance card or member portal to confirm your plan type. Review the table above for details on each plan type and how the different plans impact coverage at facilities both in-network and out-of-network as well as referral requirements and cost structures.
Before reaching out to specific facilities to confirm coverage details for your plan type, it is a good idea to narrow your choices to only a few facilities that will meet your care needs and are most likely in-network with CareFirst. You can filter facilities by treatment needs and location, and see whether a facility commonly works with CareFirst plans. Review the filtered results to compare programs based on your specific treatment needs.
Ghost networks
It’s important to know that some people may run into what is called a ghost network, which is when providers listed as in network are not actually available, no longer accept the plan, or have extended wait times. If you run into a ghost network, you can do the following:
Request your Evidence of Coverage: This will outline CareFirst's contractual obligations to you, and if in-network options aren’t available, your plan may be required to cover out-of-network care at in-network rates.
It is also important to determine how your CareFirst plan would apply to the facilities you are interested in. If you reach out, many rehabs will verify benefits for you at no cost and they can often tell you whether the program is in network, what your potential costs could be, and if there are any limitations on length of stay for treatment.
CareFirst will often require prior authorization for certain levels of care like detox, residential, or inpatient treatment. When you reach out, consider asking the facilities on your shortlist the following questions:
Is this program in network with my specific CareFirst plan?
Do you handle prior authorization and ongoing insurance reviews?
What costs, if any, should I expect after my deductible is met?
If coverage changes, will you help plan next steps in care? If so, how?
After you create a narrow list of options with clear coverage details, you’ll most likely be deciding between just a few programs. To make a final decision, try to focus on whether the program is the best fit for you and where you are. There are many factors to consider, such as:
The facility’s experience with treating your specific needs
Family involvement in treatment and aftercare options
How the program supports care if insurance coverage changes
Learn how different treatment levels work and how clinicians determine the right level of care.
See below for facilities that report accepting CareFirst BlueCross BlueShield. Before you make a final decision about treatment, ensure you follow the steps above to confirm network status, coverage, and out-of-pocket costs.
Acceptance of CareFirst BlueCross BlueShield does not guarantee coverage. A facility may say they accept CareFirst, but coverage will still depend on your specific plan and your medical needs. If coverage is denied, ask about options for appealing the decision.