Ever since the Affordable Care Act was drawn, many more American residents have been able to sign up for health insurance.
Despite this, several individuals don’t understand how to choose the right plan for their needs.
Selecting the wrong plan can be financially devastating, especially if the patient is dealing with a substance abuse condition.
There’s also a risk of signing up for obscure policies. The Affordable Care Act has made it legally binding for insurance providers to supply addiction treatment, but the protection itself can be unclear.
Both HMO and PPO insurance should be able to cover rehab and addiction treatment, but your policy may have certain restrictions or conditions.
For instance, coverage for PPO plans only begins after the patient pays a certain amount first. An HMO plan may require the patient to only receive treatment from an in-network facility.
We’ll look at these different plan types in more detail below. You’ll learn about the differences between the two and which plan is better for patients seeking rehabilitation treatment.
PPO Insurance Coverage For Rehabilitation
Treating addiction nearly always starts with the patient undergoing a medically supervised detox period, but some PPO plans won’t cover this.
This isn’t very common though, as the Affordable Care Act specifies that substance abuse treatment needs to be handled the same way as mental health treatment would be.
After the detox period, the patient needs to work on overcoming their mental addiction and trauma.
All insurance providers are required to offer substance abuse coverage, but the way each provider does this can vary.
A PPO plan might not cover a rehab stay whatsoever. However, if an insurance plan does restrict the extent of substance abuse treatment, the same conditions must be placed on mental health treatments.
An average stay in residential rehab lasts between 30-105 days. Patients that choose an outpatient program usually need more, usually a minimum of 120 days.
The length of time that PPO insurance will cover, for both inpatient and outpatient rehab, will depend on your policy’s specifications.
HMO Insurance Coverage For Rehabilitation
All HMO plans will employ a group of physicians and health facilities that are contracted to provide several health care services.
The majority of HMO plans cover rehab services, but these will have certain conditions. A few examples include:
- The patient can only go to an in-network rehab facility
- The patient needs to be referred by an in-network doctor first. They will tell the HMO provider whether or not you need treatment
- The out of network health care you may need will have substantial restrictions
An HMO plan will connect you with a main care physician who will determine the extent of the treatment you will need.
This individual will deliver most of the medical care and will link you with any other specialists, if necessary.
HMO payments are usually low, as any copayments and deductibles tend to be small. In the case of rehab, HMOs can have advantages and disadvantages.
They may be reasonably priced, but the patient won’t have as much say in choosing the facility they prefer.
If the initial doctor doesn’t believe the patient needs treatment, they can ask for a review, where another physician provides their opinion.
If the second doctor believes that treatment isn’t essential, the patient won’t receive coverage.
If this occurs, you can appeal the decision and if required, may take it to a third-party organization. However, if you are in this position, going through with all of the appeals can be time-consuming.
The process will become even more complicated if the HMO isn’t linked with a rehabilitation service.
PPO vs HMO Plans
HMOs and PPOs have differences in network size, access to medical specialists, affordability, and out-of-network insurance. We’ll go over these factors in more detail below.
Both PPOs and HMOs use networks that help to lower the price of health care. Network providers will supply discounts for the accessibility to the health plan’s members.
This also helps the members save money, through lower premiums, copayments, and deductibles.
PPO networks are usually more extensive, as compared to HMOs, you can choose from a greater range of physicians and facilities.
Despite this, each plan and network will differ with each provider, so always research thoroughly before choosing.
Primary Care Individual
HMOs will need the patient to choose a primary care physician. This person will be your main contact point during your treatment.
The PCP will assess what treatments and specialized care are needed.
However, an HMO won’t cover specialist costs unless the PCP deems it necessary. PPOs won’t usually need a PCP, so the patient will be able to see a specialist and have the cost of this paid for.
Out Of Network Insurance
If you receive care from in-network providers, the costs for both PPO and HMO plans will be at their lowest. HMOs won’t cover out-of-network facilities at all, unless it’s an emergency.
PPOs can provide some coverage for these facilities, but their coverage for in-network providers will be better.
Health Plan Cost
As PPOs provide more coverage and choice, these plans tend to cost more than HMOs. You should also take deductibles into account. Deductibles are the health care costs you need to pay before your coverage starts. Some HMOs will have deductibles, but these are normally lower than PPO ones.
Conclusion Which Is Better For Rehab HMO Or PPO?
Both HMO and PPO plans can cover addiction treatment, but the right for you will depend on your preferences and circumstances.
If finance is an issue, an HMO may be the best choice, as the price of these is usually much lower than PPOs.
However, you won’t be able to have control over which rehabilitation service you go to.
If the range of choice matters more than the cost of care, you may prefer to go with a PPO. You won’t need a referral from a primary care physician and you’ll have more doctors and rehab facilities to choose between.
PPOs may provide coverage for some out-of-network providers, though this will depend on your plan.
PPO plans may offer more choice, but there may be an HMO plan whose network includes one of your preferred providers.
No matter which plan you choose, always check to see if this is the case, as keeping in-network will keep the costs down.
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