Guide to HMO Insurance Coverage for Addiction Treatment

Last Edited: December 29, 2023
Bianka Fisk
Clinically Reviewed
All of the information on this page has been reviewed and certified by an addiction professional.

Treatment for drug and alcohol addiction covered by your HMO insurance.

Click Here for a confidential benefits check or call (866) 578-7471 to speak to a addiction specialist.

Since the Affordable Care Act, millions of Americans have suddenly been able to get much needed health insurance plans. However, since this continues to be a relatively new concept for many, few truly understand how to choose a plan that works for them. Choosing the wrong one can have tremendous financial consequences, particularly if you suffer from a chronic condition such as a substance abuse problem.

If you have the right plan for your needs, you can now receive the medical attention you need without crippling yourself financially. However, there is also the possibility that you have a coverage that is unclear and that has huge gaps in places where you need to be covered the most. While the Affordable Care Act and the Mental Health Parity and Addiction Equity Act have made it a legal requirement for insurance companies to cover addiction treatment in the same way as they treat mental health problems, exactly what this coverage can be is somewhat of a gray area.

If you have HMO insurance, you should be able to have access coverage that is required for substance addiction and rehab treatment. However, there are still many things that may not be covered, and you need to look into exactly what those restrictions are. There are several ways to do this, including checking your policy documents, visiting the HMO website, contacting them directly or asking a rehab facility to complete an insurance check on your behalf. Whatever method you choose, it is free, no obligation, and 100 percent confidential and discreet. It also won’t affect your insurance premiums.

If you are sick and tired of being sick and tired, then now is the time to act. Call (866) 578-7471.

HMO Insurance Coverage for Alcohol and Drug Rehab

Various reports and studies have shown that around 31 percent of people in this country have a type of HMO. If you are one of them, it is important that you have a sufficient understanding of what an HMO is and how it works. Basically, all HMO packages use a managed care system, meaning that they have created a network of contracted health care providers, like doctors and hospitals, who are contracted to deliver a range of services that can be used by HMO members meet their medical needs.

Almost all HMO plans have rehab services included, but they do have some restrictions in place. These restrictions may mean that it can be quite hard to find the service that you want. Some of the restrictions are:

  • That you cannot go to just any rehab facility, but most go to an in network one
  • That you must be referred by an in network primary care physician, who will inform the HMO that you require treatment
  • That there are significant limitations in terms of the out of network health care that you can receive

HMO Insurance Will Help You Get Treatment

If you have an HMO, you will be linked to a primary care physician, who will be responsible for determining any treatment that you may need. This physician will also give you most of your medical care and will refer you to other specialists who are also in the network should you need one. The payments associated with an HMO are very low, with only small co-payments and small deductibles being in place. When you apply this to a rehab facility, you will find that having a HMO can work both in your favor and against you. It works in your favor because it is available and affordable, but you don’t have as much choice when it comes to picking the service that you like. You also need to make sure that there are any rehab facilities in your area that have partnered with your HMO. If there are any, then you can be referred by your primary care physician, who will tell the insurance carrier that there is a medical need for you receiving treatment.

The first step to getting treated, therefore, is to be referred by your assigned primary care physician, but there are many other steps to complete. First of all, before the HMO agrees to pay for your treatment, they may request for a review to be conducted, asking another primary physician for a second opinion. If this physician does not feel that you need treatment, coverage will be denied. You can, however, challenge this in an appeal, and should your appeal also be denied, you can take it further to a third party state organization, particularly if you feel you have medical reasons to go into treatment. The huge downside to this is that, if you are in a position where you feel that you need treatment and it is denied, you probably don’t have the time to make all these appeals. Another difficulty is that not all HMO’s have a partnership with a rehab facility. In this case, the entire process becomes even more difficult.

HMO Insurance and Out of Network Alcohol and Drug Rehab

There are several reasons as to why you may want to go out of network. For instance, you may feel more likely to succeed if you fully remove yourself from your environment. Or perhaps your HMO does not have any partnerships with a rehab facility. What this means in terms of the coverage you have depends on which HMO you are insured with. All HMO’s try to keep their costs down by partnering with specific providers who tend to send out lower bills than what they would to an individual patient. If you don’t go to an in network provider, therefore, this contract is not in place and that means your HMO will be charged the same as a regular patient.

These higher prices can be handled using one of two methods. Firstly, the HMO may ask you to pay for the difference in price, while at the same time increasing your co-insurance, deductible, and/or co-pay charge. Secondly, they may deny you treatment coverage, which means you have to pay all of your treatment out of your own pocket.