Does Aetna Cover Rehab? What Your Plan Pays For

Aetna is one of the largest health insurance carriers in the United States, covering approximately 39 million people through employer-sponsored plans, individual marketplace plans, Medicare Advantage, and Medicaid managed care. Under the Affordable Care Act and the Mental Health Parity and Addiction Equity Act, all Aetna plans sold on the marketplace must cover substance use disorder treatment — including detox, inpatient rehabilitation, outpatient programs, and medication-assisted treatment — at the same level as other medical conditions.

What Does Aetna Cover for Rehab?

Aetna covers the full continuum of addiction treatment services when medically necessary:

Covered Services

Medical Detoxification — Medically supervised withdrawal management in hospital-based or freestanding detox facilities. Typically covered at the same rate as inpatient treatment (60-80% after deductible). Duration covered based on medical necessity, typically 3-14 days depending on substance.

Inpatient/Residential Treatment — 24/7 residential treatment programs. Aetna covers 60-80% of costs after deductible for in-network facilities. Coverage duration varies by medical necessity, with typical initial authorization for 7-14 days, followed by concurrent review for continued stay.

Partial Hospitalization Program (PHP) — Day treatment programs providing 6+ hours of programming daily. Covered at 70-90% after deductible.

Intensive Outpatient Program (IOP) — Structured outpatient treatment 3+ days per week, 3+ hours per day. Covered at 70-90% after deductible.

Outpatient Therapy — Individual and group therapy sessions. Covered at 80-90% after deductible, with typical copays of $25-$60 per session depending on plan.

Medication-Assisted Treatment (MAT) — All FDA-approved medications for substance use disorder, including:

• Buprenorphine products (Suboxone, Sublocade, Zubsolv)
• Methadone (through certified OTPs)
• Naltrexone (Vivitrol injection, ReVia tablets)
• Acamprosate (Campral)
• Disulfiram (Antabuse)

Coverage: 80-90% after deductible, depending on prescription drug tier and whether generic is available.

Aetna Plan Types and Rehab Coverage

Aetna PPO (Preferred Provider Organization)

Best for: Maximum facility choice and flexibility

Network: Nationwide network of 1,800+ addiction treatment facilities Out-of-network: Covers out-of-network facilities at reduced rate (typically 50-60%) Referrals: Not required Typical coverage: 60-80% in-network, 40-60% out-of-network after deductible Average out-of-pocket for 30-day inpatient: $6,000-$20,000

Aetna PPO plans offer the most flexibility for accessing specialized treatment programs, including facilities in other states or programs specializing in specific populations or approaches.

Aetna HMO (Health Maintenance Organization)

Best for: Lower premiums with local network access

Network: Regional network varies by location Out-of-network: Not covered except for emergency stabilization Referrals: May be required from PCP Typical coverage: 70-85% in-network after deductible Average out-of-pocket for 30-day inpatient: $5,000-$17,000

HMO plans require you to stay in-network but often have lower deductibles and out-of-pocket maximums than PPO plans.

Aetna EPO (Exclusive Provider Organization)

Best for: PPO-level benefits at lower cost, but in-network only

Network: Similar to PPO network Out-of-network: Not covered except emergencies Referrals: Not required Typical coverage: 65-80% in-network after deductible Average out-of-pocket for 30-day inpatient: $5,500-$18,000

EPO plans are a middle ground between PPO and HMO — no referrals needed, but no out-of-network coverage.

Preauthorization Requirements

Aetna requires preauthorization for all inpatient and residential substance abuse treatment. Here’s how the process works:

Before Treatment

1. Clinical assessment — You’ll undergo an intake assessment at the treatment facility
2. Facility submits authorization — The facility’s utilization review team submits a preauthorization request to Aetna’s behavioral health department
3. Aetna reviews request — Behavioral health clinicians review the request using ASAM (American Society of Addiction Medicine) criteria
4. Authorization decision — Typically within 24-48 hours for urgent requests, up to 72 hours for standard requests

During Treatment

Concurrent review: Aetna conducts ongoing reviews every 3-7 days during your stay to assess continued medical necessity. The treatment facility provides clinical updates showing your progress and need for continued care.

Discharge planning: Aetna works with the facility to ensure appropriate step-down care (e.g., transitioning from inpatient to IOP) is authorized.

Medical Necessity Criteria

Aetna uses ASAM criteria to determine medical necessity, evaluating:

• Acute intoxication and withdrawal potential
• Biomedical conditions and complications
• Emotional, behavioral, or cognitive conditions
• Readiness to change
• Relapse, continued use, or continued problem potential
• Recovery environment

Typical Out-of-Pocket Costs with Aetna

Your actual costs depend on your specific plan’s deductible, coinsurance, and out-of-pocket maximum. Here’s a typical example:

Example: Aetna PPO Plan

Plan details:

• Deductible: $2,000 (individual)
• Coinsurance: 80/20 (Aetna pays 80%, you pay 20%)
• Out-of-pocket maximum: $8,700 (individual)

30-day inpatient program:

• Facility cost: $35,000 (in-network negotiated rate)
• You pay: Deductible ($2,000) + 20% of remaining $33,000 ($6,600) = $8,600 total
• If this exceeds your out-of-pocket max, you pay $8,700 and Aetna covers the rest

Medical detox (7 days):

• Facility cost: $4,900 (in-network)
• You pay: Toward deductible and coinsurance

MAT (monthly):

• Buprenorphine generic: $25-$75 copay per month
• Suboxone brand: $100-$200 copay per month
• Vivitrol injection: $50-$250 copay per month

Cost Comparison by Plan Type

Verifying Your Aetna Coverage

Before entering treatment, verify your specific coverage:

Call Aetna’s Behavioral Health Line

Aetna Behavioral Health: 1-800-424-3627

Information to have ready:

• Your member ID number
• Group number (if employer-sponsored)
• Specific facility you’re considering (name and address)

Questions to ask:

• Is this facility in-network?
• What is my deductible, and how much have I met this year?
• What is my coinsurance percentage for inpatient behavioral health?
• What is my out-of-pocket maximum, and how much have I met?
• Is preauthorization required, and how do I initiate it?
• How many days will be initially authorized?
• Does my plan cover medication-assisted treatment, and which medications?

Check Online

Aetna Navigator: Log into your account at Aetna.com

• Find a provider/facility using the behavioral health search
• View your benefits and claims
• Check deductible and out-of-pocket maximum progress

Have the Facility Verify Benefits

Most treatment facilities have dedicated insurance verification specialists who will:

• Call Aetna on your behalf
• Obtain a benefits breakdown
• Provide you with estimated out-of-pocket costs
• Initiate the preauthorization process

This is typically the easiest path, as facilities are familiar with Aetna’s processes.

Aetna’s Behavioral Health Network

Aetna contracts with over 1,800 addiction treatment facilities nationwide, including:

• Hospital-based detox and inpatient programs
• Freestanding residential treatment centers
• Intensive outpatient programs (IOP)
• Partial hospitalization programs (PHP)
• Medication-assisted treatment providers
• Opioid treatment programs (OTPs) for methadone

Network strengths:

• Particularly strong coverage in the Northeast (NY, NJ, PA, CT, MA)
• Extensive Mid-Atlantic network (MD, VA, NC)
• Growing coverage in Southeast and Southwest

Network considerations:

• Rural areas may have fewer in-network options
• Specialized programs (executive rehab, dual diagnosis centers) may be out-of-network
• Network adequacy requirements ensure access within reasonable distance

What If Your Aetna Claim Is Denied?

If Aetna denies coverage for treatment, you have appeal rights under federal law:

Internal Appeals

1. Request a review — Contact Aetna within 180 days of denial
2. Submit additional information — Provide additional clinical documentation supporting medical necessity
3. Review timeline — Aetna must respond within 30 days (or 72 hours for urgent appeals)

External Review

If internal appeal is denied:

1. Request external review — Independent review organization evaluates your case
2. Timeline — Decision within 60 days (or 72 hours for urgent)
3. Binding decision — Aetna must comply with external reviewer’s decision

State Insurance Department

File a complaint with your state insurance department if you believe Aetna violated mental health parity laws or your plan terms.

Don’t Have Aetna (or Any Insurance)?

If you’re currently uninsured, getting coverage is often the most cost-effective path to treatment. A 30-day inpatient program costs $15,000-$50,000 without insurance, while monthly premiums for a PPO plan with comprehensive addiction coverage typically cost $400-$750 — a fraction of out-of-pocket treatment costs.

All ACA-compliant plans — including Aetna marketplace plans — must cover substance use disorder treatment as an essential health benefit. A licensed insurance specialist can help you:

• Understand marketplace plan options during open enrollment
• Check for qualifying life events that allow special enrollment
• Compare plans based on treatment coverage and network access
• Navigate subsidies and cost-sharing reductions

Sources

• Aetna. “Behavioral Health Benefits.” Member Benefits Portal. 2026.
• Centers for Medicare & Medicaid Services. “Mental Health Parity and Addiction Equity Act.” 2024.
• Healthcare.gov. “Mental Health and Substance Use Disorder Coverage.” 2026.
• National Association of Insurance Commissioners. “State Health Insurance Assistance Program.” 2026.