(Please note: Rehabs.com strives to provide you with the most updated information on each carriers' addiction insurance coverage but policy changes and errors do occur. Please check with your insurance carrier directly to confirm coverage levels. Rehabs.com is an informational site only and is not affiliated or sponsored by any insurance providers.)
Choosing a health insurance plan can have long-lasting financial consequences.
"Choosing a health insurance plan can have long-lasting financial consequences."
With the right plan in hand, you can receive excellent medical care at a price that won't empty your savings, while the wrong plan can be financially costly and leave you with questionable coverage that has gaping holes in what's allowable under the plan and what isn't. For most individuals, HMO insurance provides the coverage needed for drug addiction and rehabilitation treatment. For help in finding a rehab facility that can help you on your path back to a clean and sober lifestyle, call your insurance provider for more information.
Managed Care Plans
According to Consumer Reports, about 31 percent of Americans belong to some sort of HMO. If you're one of those who belong to an HMO plan, it's important to know how the typical HMO does business. An HMO operates through the use of managed care. They contract directly with healthcare operators, such as hospitals and doctors, to provide a network of servers the members of the HMO can use for their medical needs.
Rehab services are widely available under most HMO plans, but restrictions exist that may make getting services difficult, including:
- Limitations on rehab facilities available for use
- The need to convince a primary care physician that treatment is necessary
- Limits on out-of-network care
- Reviews of healthcare recommendations made by your physician by the HMO administration
Under HMO insurance coverage, you'll find yourself assigned to a primary doctor who oversees your treatment. This doctor will provide most of your care, using mostly those healthcare professionals already within the HMO's network of contracted partners. The payment for care is kept low, with you having to pay a small deductible as well as a small co-payment. When it comes to rehab services, working within an HMO can have a variety of results as to just what services you may find available. If the HMO has treatment facilities as partners, then your primary care physician must recommend the specialty treatment before you can enter into a rehab center.
Having the physician recommend you for treatment is only the first step toward getting rehab treatment for an addiction though. The HMO can do a review of the recommendation before allowing you to receive the treatment, deciding if the treatment is truly necessary. You may be denied treatment due to this review, but an appeals process is generally available to HMO members to challenge such a denial. Even if the appeal is denied, outside state-run organizations can often provide independent reviews, but these are usually limited to rejections due to medical reasons and not contract restrictions. For HMOS without existing rehab partnerships, the process can be a bit more difficult.
When your HMO lacks a rehab or addiction treatment center partnership, you may have to go outside the HMO network to receive treatment. The results of going outside your HMO network for care differs according to the particular HMO through which you're insured. The contracted partnerships are a way of keeping costs of medical care down, with the medical providers often billing the HMO less than they would bill you directly as a patient. When you go outside the network, the HMO has no contracted billing price with that particular addiction/rehab center, so the price may be higher than it would be for a partnered facility. You can find the right rehab facility in your area by calling your insurance provider to speak to a knowledgeable operator with a list of programs and facilities that match your particular rehabilitation needs.
The HMO handles these higher prices in one of two ways. Either the HMO passes on the difference in price to you, while also charging you a higher co-pay, deductible or co-insurance rate, or the HMO may decide not to cover the cost of rehab or the out-of network healthcare at all, leaving you to pay the total yourself.