When you or someone you love is considering treatment for a substance use disorder, the range of options can feel overwhelming. Detox, inpatient care, outpatient programs, sober living, medication—where do you even begin? The good news is that addiction professionals use a shared framework to match each person with the right level of support. It's called the ASAM Criteria, developed by the American Society of Addiction Medicine, and understanding it can help you navigate treatment and your NYSHIP coverage with more confidence.
This article is educational and is not medical, insurance, or legal advice. Always confirm details with a licensed clinician and with your specific plan.
The ASAM Criteria is the most widely used set of guidelines in the United States for placing patients into the appropriate level of addiction care. Rather than a one-size-fits-all approach, it evaluates each individual across six dimensions—things like withdrawal risk, medical and mental health conditions, readiness to change, and living environment. Based on that assessment, a clinician recommends a level of care that fits the person's current needs.
Because these levels are standardized, insurers—including NYSHIP and The Empire Plan—often reference ASAM guidelines when reviewing whether a treatment level is medically necessary. Knowing the levels can help you understand what a provider is recommending and why.
ASAM describes care along a continuum, generally organized into broad levels numbered from 0.5 through 4. Higher numbers mean more intensive, structured care. People can move up or down the continuum as their needs change—this is a strength of the model, not a failure. Recovery is rarely a straight line.
This is the lightest level of service, aimed at people who show risky substance use but may not yet meet the full criteria for a substance use disorder. It often includes education, screening, and brief counseling to prevent problems from escalating.
Outpatient treatment typically involves fewer than nine hours of structured services per week for adults. It may include individual therapy, group counseling, and medication management, and it allows people to continue living at home while attending appointments. This level works well for those with stable environments and lower-intensity needs. You can learn more about how this may apply to your benefits on our NYSHIP outpatient treatment page.
Level 2 steps up the intensity for people who need more support but don't require 24-hour care.
At Level 3, individuals live at the treatment facility and receive 24-hour support. This tier includes several sublevels—ranging from clinically managed low-intensity residential care (such as certain sober living arrangements) to medically monitored intensive inpatient programs for people with significant medical or psychiatric needs. Residential care can be especially helpful when a person's home environment makes recovery difficult or when they need round-the-clock structure.
This is the most intensive level, delivered in a hospital-like setting with 24-hour medical and nursing care. It's designed for people with severe, unstable conditions—such as complicated withdrawal or serious co-occurring medical issues—who need immediate, physician-directed treatment.
Withdrawal management, often called detox, appears across several ASAM levels depending on how medically complex the withdrawal is expected to be. Some people can detox safely in an outpatient setting, while others—particularly those withdrawing from alcohol or benzodiazepines—may need medically monitored or medically managed care to stay safe. If you're weighing your options, our page on alcohol detox treatment explains what to expect. According to the SAMHSA National Helpline, treatment and detox services are available nationwide, and the right setting depends on your individual health picture.
Across many of these levels, providers may use FDA-approved medications to treat opioid or alcohol use disorders. The National Institute on Drug Abuse notes that medications combined with counseling and behavioral therapies are often the most effective approach. If this is relevant to you, see our overview of medication-assisted treatment.
Many people entering treatment also live with mental health conditions like depression or anxiety. Programs that address both at once—known as integrated or dual diagnosis treatment—are increasingly common and often produce better outcomes. The ASAM assessment specifically accounts for these overlapping needs.
NYSHIP plans, including The Empire Plan, generally provide coverage for substance use treatment across multiple levels of care, though the specifics—copays, prior authorization, network requirements, and covered levels—depend on your particular plan and coverage details. Federal mental health parity protections generally require that behavioral health benefits be comparable to medical and surgical benefits, but the exact terms vary.
Because insurers often reference the ASAM Criteria when determining medical necessity, understanding these levels can help you advocate for appropriate care. For a deeper look at what your plan may include, visit Does NYSHIP cover rehab?, our Empire Plan rehab coverage guide, and our detailed breakdown of the levels of addiction care. You can also review official benefit information through the New York State Department of Civil Service.
The clearest path to answers is often a benefits verification. Our team can help you check coverage and understand your options—call 213-321-6518 to verify benefits or get help, or start online through our NYSHIP coverage verification page.
The ASAM framework exists because addiction affects each person differently. A young professional with a stable home and mild alcohol use disorder needs something very different from someone facing severe opioid withdrawal or homelessness. Matching the level of care to real needs improves both safety and long-term recovery, and it prevents both under-treatment and unnecessary, costly care. It also allows treatment to adjust over time as you progress.
If you or someone you love is in crisis or having thoughts of suicide, help is available 24/7. Call or text the 988 Suicide & Crisis Lifeline by dialing 988. For confidential, free treatment referrals and information at any hour, contact the SAMHSA National Helpline at 1-800-662-4357. Reaching out is a sign of strength, and support is closer than you might think.
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