Understanding PPO and HMO Addiction Treatment Benefits

An Overview of PPO and HMO Plans

Understanding the different types of addiction treatment health insurance plans available to you is the first step in using your benefits to help pay for addiction treatment. PPO and HMO plans are both medical plans designed to help Americans afford the many expenses associated with health care. PPO and HMO addiction treatment and health care coverage may seem similar at a glance but are very different in practice. 

PPO (Preferred Provider Organization) plans are a type of medical insurance plan for addiction treatment in which individuals and their families are encouraged to select from a list of in-network healthcare providers including doctors, hospitals, and other healthcare professionals. Networks are made up of contracted medical professionals and health insurance companies, who are known as preferred providers. These providers offer their services to policyholders within the PPO at lower rates than they would charge if the insured individual were not in the PPO, and the insurers pay the PPO a fee to access their network of providers. 

PPO plans offer comprehensive coverage with a wide range of providers and services. Those enrolled in a PPO are free to use the services of any provider in their network and don’t need referrals to see a specialist but are encouraged to name a primary care physician. They can also use care outside of their network but will pay more than staying in-network. 

An HMO (Health Maintenance Organization) is another insurance structure that provides coverage for medical care through a network of physicians. When you’re in an HMO, your primary care physician (PCP) must be your first point of content and provide referrals to specialists and you must stay within a typically smaller range of providers to use your insurance coverage. Out-of-network care won’t be covered, except in specific scenarios, like emergency care or dialysis. HMOs focus on prevention, integrated holistic care, and wellness.

Generally, HMOs have lower premiums than PPOs. They aim to provide basic and supplemental health services at fixed, lower prices established using a community rating system. Under an HMO system, users pay a monthly or annual premium for access to in-network providers, and they must also live or work within the plan’s network area to be covered. If a person enrolled in an HMO uses out-of-network care, they must pay out of pocket.

 

How PPO Plans Cover Addiction Treatment

When you’re covered under a PPO plan, your addiction treatment coverage will depend on your needs, as well as your insurance plan. Not all PPO plans cover treatment for substance use disorders.

PPO insurance may cover some or all treatments, including drug detox, medication-assistant treatment (MAT) programs, inpatient and outpatient rehab, and mental health treatments. It may also cover certain evidence-based therapies and treatments, such as cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), neurofeedback, and family therapy. 

PPOs are the least restrictive type of insurance coverage for addiction rehab, so you may find that you have more treatment options than those with other types of insurance. You also don’t need a referral from your primary care physician to get coverage. 

Understanding HMO Coverage for Addiction Treatment

HMO plans require their participants to get all care services from providers within their networks, with a referral from their primary care provider who will arrange and coordinate treatment. This means that the treatment center you go to must be in-network with your insurance company. 

HMOs will usually cover substance use disorder treatment and care for mental health conditions, but your unique health insurance plan will determine the degree to which your treatment is paid for, along with how much you’ll have to pay yourself. 

Comparing Costs and Coverage: PPO vs. HMO for Addiction Treatment

It’s always a good idea to check with your PPO and HMO addiction treatment insurance provider before starting treatment so you know how much to expect to pay out-of-pocket and how much will be covered by your insurance. You may wish to call your insurance company or speak to the addiction treatment facility for help. 

PPO plans include several costs, with higher premiums than other insurance plans. If you are part of a PPO plan, you will be responsible for copayments during your appointment or treatment. You will likely also have to meet a deductible, which is a certain amount you must pay out of pocket each year before your insurance kicks in. Some types of treatments, like equine therapy or art therapy, may not be covered by all insurance plans, while others may be partially or fully covered.

The PPOs that cover substance use disorder treatment usually have the highest deductibles and higher-than-average premiums because they also have more flexibility and larger networks than other insurance types. 

HMO insurance plans for addiction treatment let you pay lower premiums, but you may have reduced access to certain services within a smaller network of assigned preferred providers. HMO plans don’t normally have deductibles, but if you want to see a specialist you will require a referral from your primary care physician. 

Choosing between PPO and HMO insurance usually comes down to what is offered through your workplace, where you live, and the balance between the cost of the plan and the accessibility of treatment providers to you.

The Pros and Cons of PPO and HMO Plans in Addiction Recovery

Pros of PPO plans are:

• A larger network of providers is available
• You don’t need to select a primary care physician
• No referrals are required to see a specialist
• More flexibility 

Cons of PPO plans are:

• Higher premiums, deductibles, and copayments
• You have to ensure your care provider is in-network to avoid paying out-of-pocket

Pros of HMO plans are:

• Less expensive overall
• A primary care physician will direct your treatment 

Cons of HMO plans are:

• Must see in-network providers
• Need a referral to see a specialist
• Only certain emergencies are covered

 

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Navigating Insurance for Addiction Treatment: Tips and Strategies

It doesn’t have to be stressful trying to navigate your PPO and HMO Addiction Treatment Insurance while dealing with mental health and addiction. If you’re unsure how your insurance works, you are not alone. Copays, deductibles, in-network and out-of-network providers, and coverage limits can be confusing. 

To get started, you may want to talk to your insurance company (or read your policy carefully) to see what types of treatment will be covered and how much you may have to pay out-of-pocket. You can check whether your area’s rehab centers are in-network or ask an insurance agent for a list of approved treatment centers. If you’re in an HMO, you will have to talk to your primary care physician about seeking treatment, and if you’re covered under PPO insurance you can get started on your own by calling the rehab center. 

How to Work with Your Insurance for Effective Addiction Treatment

At WhiteSands, we are here to help you through this challenging time and help you understand your insurance coverage. Most of our clients use their health insurance to cover the cost of their treatment, so we are very familiar with how PPO and HMO addiction treatment insurance works. Call us anytime, and we can help walk you through the process. 

Once you give authorization, we can speak to your insurance company directly to find out what benefits are covered while learning what treatments will work best for your unique needs from your qualified healthcare provider and let you know what to expect financially within just a few hours. If your insurance doesn’t cover all of your treatment, you may be able to access payment plans, treatment scholarships, grants, or a loan. 

WhiteSands Treatment’s Approach to PPO and HMO Plans

At WhiteSands Treatment, we only accept out-of-network insurance plans, and we are happy to work with any major health insurance company to find a solution that fits your coverage. We have customizable treatment plans that can be modified while still providing you with the best treatment in our luxurious, safe treatment center. 

Whether you have a PPO plan or an HMO plan, at WhiteSands Treatment, we will ensure your plan is tailored to suit your health and wellness needs first while keeping your financial needs in mind. To find out more or to verify your insurance coverage, please call us at 877-855-3470. Your call will be 100% confidential, and we will help you navigate your PPO and HMO Addiction Treatment Plans while getting the help you need to move into long-lasting recovery.

If you or a loved one needs help with abuse and/or treatment, please call the WhiteSands Treatment at (877) 855-3470. Our addiction specialists can assess your recovery needs and help you get the addiction treatment that provides the best chance for your long-term recovery.