HMO Insurance Coverage for Drug & Alcohol Rehab Treatment
Does HMO Insurance Cover Alcohol and Drug Rehab?
A health maintenance organization (HMO) is a type of insurance plan that may provide you with various health benefits, including coverage for mental health and substance use disorder coverage. This means that you may be able to use your HMO health plan to cover some or all the costs related to drug and alcohol rehab.
What is covered by your HMO plan will vary based on your specific plan’s design. As such, it’s important that you call the number on the back of your insurance card to learn what is covered under your specific policy. Alternatively, you can work directly with your rehab center of choice, and they should be able to help you verify your benefits.
What Is an HMO?
HMOs have been around for nearly a century.1 The origins of managed care plans, such as HMOs, date back to as early as 1929.1 The early versions of HMOs were known as prepaid health plans, and the term “health maintenance organization” was coined in 1970.1 The Health Maintenance Organization Act of 1973 helped to expand managed health care and stimulate competition within health care markets to help give employees access to affordable health care.1
Present-day HMOs are characterized as a type of health plan that covers specific services obtained with the plan’s network.2 Unlike other types of health plans, HMOs typically limit coverage for members to providers who are within the HMO network.2 You generally must work with your provider to coordinate your care as well. Additionally, HMOs generally do not provide coverage for services rendered outside of your network unless it’s a medical emergency.2
What Will HMO Insurance Cover?
What is covered under your HMO health plan will vary based on the insurer and the plan that you have. Some of the following common treatment methods may be fully or partially covered under your HMO:
- Inpatient or residential rehab. With an inpatient or residential rehab program, you will stay at the rehab facility for the duration of your care. You will receive 24/7, round-the-clock medically supervised care, which could include medical detox, while you’re in one of these treatment programs.3, Pg 8, “What types of treatment programs are available?” Para 2,
- Outpatient rehab or therapy. With outpatient rehab programs, you will go to the provider 1 or 2 times a week to get the care you need, but you don’t need to stay overnight. Most outpatient rehab services include therapy, meetings, or counseling services.3, Pg 10, Para 2
- Intensive outpatient programs. With intensive outpatient programs (IOPs), you receive more structured outpatient health care services than standard outpatient rehab or therapy programs. You typically must attend a minimum number of hours of treatment each week.3, Pg 10, Para 3
- Partial hospitalization programs. With partial hospitalization programs (PHP), which are also called day programs, you would go to a facility and receive your treatment(s) for 4-8 hours a day, multiple days a week. Overnight stays are typically not required.3, Pg 10, Para 1
Be sure to call the number on the back of your HMO insurance card to find out exactly what may be covered under your plan.
Does HMO Insurance Cover Mental Health Treatment Facilities?
Mental health treatment facilities across the country provide a variety of mental and behavioral health services. Whether your HMO plan provides coverage for treatment at these facilities depends on your specific health plan. However, almost all U.S. health plans are required by the Affordable Care Act to provide coverage in some capacity for mental health treatments.4 Coverage can vary and may not be the same across all insurers’ HMO plans.
What this means is that your HMO plan may provide coverage for stand-alone heroin rehab as well as co-occurring disorder treatment. Someone who experiences a substance use disorder and mental illness at the same time is said to have a co-occurring disorder.5
While it’s not believed that one directly causes the other, having a mental illness increases your risk for substance use disorder and vice versa.6 Because the two are interconnected, having integrated treatment for co-occurring disorders, where each condition is treated as its own at the same time.5 “What should I do?”
How Long Does HMO Insurance Cover Rehab?
The length of time that your HMO plan will cover rehab will vary based on your specific plan. Every insurance company treats rehab differently. Call the number on the back of your insurance card to learn more about your plan’s information. No matter what your insurance plan will cover, it’s important to know that remaining in rehab for an appropriate length of time is crucial to your recovery.
Additionally, longer treatment times tend to be considered the most effective. According to research, treatment should last for at least 3 months to help patients stop or reduce drug use and see improved overall outcomes.7, bullet 5 Please note that everyone’s needs are different, and you may need more or less time in rehab.
What if My HMO Policy Does Not Cover Rehab?
If your HMO health plan doesn’t cover rehab costs, you may need to pay for out-of-pocket care costs. Depending on the rehab center you choose, there may be payment options available to you. Some of these payment options can include financing or scholarship options. Be sure to ask the rehab center whether any of these would be available to you. Prioritizing getting the care you need today is crucial, as pushing it down the road can cause further issues with your mental and physical health.
HMO In-Network vs. Out-of-Network Alcohol and Drug Rehab Centers
With HMOs, you typically will only receive coverage for services obtained within your plan’s network.2 A network refers to the facilities and providers that are under contract with your HMO plan to provide services at a pre-negotiated rate.2 HMOs typically don’t provide coverage for out-of-network services unless it’s a medical emergency.2 Therefore, it is crucial that you find in-network mental health providers to help keep your health care costs low.
To verify your benefits, you can call the number on the back of your insurance card or ask rehab centers directly whether they will accept your plan.
Check HMO Insurance Coverage for Rehab & Detox Centers
If you’re searching for rehab services and have an HMO health plan, you may be wondering how you can verify your benefits and coverage. American Addiction Centers (AAC) is here to help you do just that and more.
Call the AAC helpline today and have your insurance information ready such as your HMO plan provider, subscriber information, and plan numbers. A team member can check your benefits right while you’re on the phone. AAC can also help you locate a nearby rehab center that’s in-network with your HMO plan. Don’t wait any longer. Contact us today or enter your information in the form below.
- National Council on Disability. (n.d.). Appendix B. A brief history of managed care.
- gov. (n.d.). Health maintenance organization.
- Substance Abuse and Mental Health Services Administration. (2014). What is substance abuse treatment? (Original work published 2004).
- gov. (n.d.). Mental health & substance abuse coverage.
- National Alliance on Mental Illness. (2020, May). Substance use disorders.
- National Alliance on Mental Illness. (2017, October 4). Understanding dual diagnosis.
- National Institute on Drug Abuse. (2018, January). Principles of effective treatment.