In-Network HMO, EPO and PPO Covered Addiction Rehab

/by

Working people and their families are often covered by affordable health care coverage offered through managed healthcare plans such as HMO’s (heath management organizations), EPO’s (exclusive provider organizations) and PPO’s (preferred provider organizations). The Affordable Care Act has resulted in healthcare exchanges such as “Covered California” where people can purchase affordable healthcare insurance which is priced according to their income.

HMO, EPO, and PPO insurance plans usually relegate behavioral healthcare coverage and management to behavioral healthcare departments or organizations. The reason that services provided by alcohol and drug rehabilitation and treatment centers are managed separately by behavioral health departments is that diagnoses, prognoses and progress cannot be measured through conventional biological markers or measurement tools. A specialist in behavioral health is required to determine the level and type of care needed for complex diseases such as alcoholism and drug addiction now referred to as “substance use disorders”.

Costs and personal restrictions are better contained when a professional who is financially independent from the provider oversees care and monitors costs. Treatment can become exorbitantly expensive when there exists no such oversight. For some people with wealth, rehab can be combined with an extended luxury vacation. Not everyone can or should afford luxury or lengthy treatment.

When you seek a provider contracted with your insurance healthcare plan, the coverage is much better and the services are closely monitored for quality and cost. Ethical business practices can also be enforced such as providing you and your family about the best estimate of cost before a contract is signed.

Providers who are “out-of-network” will often state that they accept insurance. Before signing contracts, take the following steps to protect yourself:

  • Ask the out of network provider if they will give you a written estimate of what the out-of-pocket cost will be after the insurance stops authorizing payment for treatment
  • Ask if they will provide you an itemized bill which they send to your insurance company, including the charges for urinalysis
  • Ask if the provider gets approved for all services rendered and ask how long the insurance company is likely to approve payment
  • Ask if they bill you the balance after the insurance company ceases to cover treatment and how much that total is likely to run.

To protect you and your family from unethical business practices or to avoid unnecessary costs and services, ask you insurance representative or therapist for their expert opinion.