Cost is often a large consideration for an individual or family member when they are calling into a detox facility or addiction treatment center, seeking help for themselves or a loved one. Typically in a crisis, the first questions revolve around what the specific rehab does and if what they do is appropriate in offering treatment services for the individual suffering from addiction.

However, once there is a mutual understanding of the nature of the addiction for the person needing help, and that the treatment center, detox, or rehab appropriately can offer medical, clinical, and therapeutic services to meet the needs of the person in active addiction, there is often questions surrounding financials and health insurance. Addiction treatment is not a small cost, especially quality addiction treatment services. So individuals and families need to know what their financial commitment will be, as well as if any of those services can be covered by health insurance. The answer to the question “Will my health insurance cover drug treatment?” is typically, yes, to some degree. Whether someone has Medicaid state insurance, private insurance like an HMO, private commercial health insurance with out-of-network benefits like a PPO, or veterans insurance like Tricare, most health insurance plans will cover some or all of a rehab or treatment stay. How much health insurance covers detox or rehab, however, depends a great deal on the treatment center itself and what types of health insurance it is able to accept, as well as the individual’s health insurance plan, the specifics of that health insurance plan, and how much things like deductibles, out-of-pocket maxes, and copays factor into a potential patient’s health insurance plan.

There is an odd phenomenon that often occurs when someone is seeking help for addiction for themselves or a loved one: They believe, for whatever reason, that detox or treatment should be free. Either free to anyone or, if that person has health insurance, they should be responsible for no out-of-pocket costs for services. While this may occur, depending on if someone has met all their responsibility on their health insurance plan, most of the time this is not the case. Whether the rehab or treatment center is for profit, not-for-profit, or non-profit, there is typically a cost associated with treatment services. And whether a detox or rehab accepts state insurance, military insurance, or commercial insurance as an in-network provider or as an out-of-network provider, in most cases there will be a financial responsibility for the patient or family to receive detox or treatment services.

The greatest issue for many people seeking treatment (as well as the general population as a whole), is that most people do not truly understand their health insurance plan. Health insurance can be confusing and cumbersome to navigate when trying to get direct answers from the health insurance companies.  What is helpful to understand is what type of out-of-pocket costs may be associated with a health insurance plan. This is true for all medical coverage, not just detox or treatment for addiction.

First, there are different types of health insurance.

  • Employer-sponsored health insurance coverage (sometimes called group or small group coverage) is the type of health insurance some usually gets through an employer through their job. Most companies offer several different plan types or plan options, including HMOs or PPOs.
  • Individual health insurance plans are health insurance coverage that an individual can enroll in by themselves, available to everyone through the Affordable Care Act (ACA).
  • Family health insurance plans, similar to individual plans, are health insurance coverage gained through the state or federal marketplace, health insurance company, or health insurance broker, that cover a family.
  • Medicaid, which provides health insurance coverage to millions of Americans, is state insurance for eligible low-income adults, children, pregnant women, elderly adults, and individuals with disabilities. Medicaid is America’s public health insurance program for individuals that are unable to afford private, commercial health insurance.
  • Medicare is the federal health insurance program that offers health insurance coverage and benefits for seniors aged 65 or older.

Next, there are different types of major medical health insurance plans that people can choose from, and they range in cost. Examples of these are:

  • Health Maintenance Organizations (HMOs) are typically health insurance plans that only allow those who have this health insurance to choose from doctors or providers that are IN-NETWORK with that specific health insurance plan. Many HMOs require a referral to specialty care from their primary care physician. HMOs will not have coverage for choosing a doctor, provider, or facility that is out of network, and HMOs tend to have lower premiums, lower deductibles, and minimum copays.
  • Exclusive Provider Organizations (EPOs) are typically health insurance plans that offer a local network of doctors, providers, and facilities to go to. EPOs are similar to HMOs, except that in most cases, EPO plans do not require a primary care doctor to be on the plan, nor do they require a primary care physician to make a referral to a specialist.
  • Preferred Provider Organizations (PPOs) are health insurance plans typically called “out-of-network” because those that have PPO insurance plans have the ability or flexibility to choose any doctor, hospital, specialist, or healthcare facility that is either in-network with the insurance or that may provide services out-of-network with the health insurance plan. While PPOs offer greater availability of care, they often have higher deductibles, out-of-pocket maximums, and copays.

Speaking of which, what ARE deductibles, out-of-pocket maximums, and copays, and some of that other health insurance jargon?

  • Deductibles are the amount of money a person with insurance must pay themselves, out-of-pocket, before their health insurance will start paying for healthcare services or treatment. As an example, if a person has a $2500 deductible, they will be responsible to pay $2500 for their medical care before insurance will begin paying.
  • Out-of-pocket maximums is a cap on how much someone with health insurance will have to pay themselves, out-of-pocket, in a single calendar year for their medical care. Once that limit is reached, the health insurance company will cover medical services in full for the remaining time during that year. For example, if a person has $10,000 as an out-of-pocket maximum for the year, if a person has paid a $2500 and also $7500 in other medical expenses that can include copays or coinsurance, they would have reached $10,000 in out-of-pocket costs, met their out-of-pocket maximum, and their health insurance will cover their medical expenses for the rest of the calendar year.
  • Copays are a cost that many plans have that patients will need to pay out-of-pocket. The cost of copays is different for each plan, but they are typically minimal. For example, a patient may owe a $10 copay each time they see their doctor, or a $15 copay for each visit to a therapist or counselor. This amount for each visit is the patient’s responsibility.
  • Coinsurance, similar to copays, is a cost sharing payment owed by the patient that they must make out-of-pocket when receiving health care or medical services.
  • Premium is the cost a person pays each month to their health insurance company in order to stay enrolled in that health insurance plan and to keep their health insurance coverage active.

Finally, when it comes to any medical care and health insurance coverage, it is important to remember that the patient is always responsible for their contracted out-of-pocket costs. So, if a patient needs to enter detox or treatment and has a $5000 deductible, and treatment costs more than $5000, the patient will be financially responsible to pay $5000 out-of-pocket. It is also important to remember that, although some facilities do this, medical providers, rehabs, and treatment facilities are required to collect that out-of-pocket cost and cannot waive it. While there are ways that facilities can help patients in financial hardship with sliding scales and payment plans, it is illegal to waive out-of-pocket costs to patients and only accept insurance reimbursement. Therefore, individuals and families should always be prepared that any level of addiction treatment, whether detox, rehab, or outpatient, will come with some level of cost, unless everything has been met for the year for their health insurance plan.

Here at Innovo Detox, we’ve worked and continue to work to offer accessible and affordable services. Currently, we are contractually in network with Highmark Blue Cross Blue Shield, Capital Blue Cross, and Blue Cross and Blue Shields Federal Employee Program (FEP), which allows Innovo to accept most all BCBS health insurance plans as an in-network provider. We are also in-network with Geisinger Health Plan, and contracted with Tricare, which allows us to accept Tricare East, Tricare West, Tricare Select and Tricare Prime. At the moment, we are able to accept patients that have Aetna, Cigna, United Healthcare and other commercial health insurance plans as an out-of-network provider but are hopeful to be able to offer more in-network health insurance options in the near future.

If you or someone you know needs help with addiction or co-occurring disorders, please give us a call. Innovo Detox offers the latest in evidence-based medical, psychiatric, and clinical care for those in need of detox and medical stabilization in Pennsylvania and the surrounding Mid-Atlantic area. If we aren’t the best fit for you or a loved one, we will take the necessary time to work with you to find a detox, rehab, treatment center or provider that better fits your needs. Please give us a call at (717) 619-3260 or email our team at info@innovodetox.com. For more information on our company or services, please visit our website at www.innovodetox.com.