How Many Addiction Treatment Stays Will PPO Pay For?

Introduction to PPO Plans and Addiction Treatment Coverage

Preferred provider organizations (PPOs) are American health insurance plans that are typically partially paid for by employers throughout the US, with roughly 46% of Americans who have a health plan enrolled in a PPO. 

Within a preferred provider organization are insurance companies that contract doctors, medical centers, health care facilities, and rehabilitation clinics to create networks of care. This type of insurance utilizes a cost-sharing system. Once you’ve met your deductible (the amount of money you have to pay per year before your insurance kicks in), then your health insurance will cover a percentage of the cost of treatment. This includes PPO addiction treatment coverage.

Preferred provider organizations are typically more expensive than other types of insurance, with higher premiums than HMOs or EPO insurance. Each insurance company differs in the type of treatments and levels of care they cover, as well as the amount of coverage they provide, their flexibility, and the premium cost.

PPOs are flexible, allowing insured clients to access in-network care and out-of-network treatments, but if you choose the network’s preferred providers you will receive a higher level of coverage, which means you will have to pay less out-of-pocket. You may not need referrals from your primary care physician to be able to see a specialist or attend addiction treatment, but for certain procedures and medications, pre-authorization may be required. 


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Understanding the Scope of PPO Coverage for Addiction Treatment

Thanks to the Mental Health Parity Act of 2008, health insurance must treat mental health disorders, including substance use disorders, the same way they would treat other health conditions. PPO addiction treatment coverage varies depending on your insurance plan, and may or may not cover treatment and services like:

  • Prescription medications used during detox
  • Medical detox programs, usually provided on an inpatient basis 
  • Inpatient rehab programs (short-term and long-term)
  • Partial hospitalization outpatient programs
  • Intensive outpatient programs
  • Aftercare services and ongoing care 
  • Medication-assisted treatment plans for opioid recovery
  • Time spent in a sober living home
  • Holistic treatments and alternative medicines

If the detox, rehabilitation program, medication, service, or recovery program is covered by your insurance within a PPO, you may first need to pay a deductible. This is a flat rate amount that must be paid by you out-of-pocket before your insurance coverage will commence. 

Before paying for addiction treatment using PPO coverage, you may first want to ensure that the treatment center is in-network and that the types of treatment you plan on attending will be covered. 

Health insurance will usually cover detox services and some inpatient and outpatient rehab, therapy, medication, support, and mental health treatments. Most of the time holistic therapies and alternative medicines are not covered. If your primary care physician notes that these treatments are essential to your health and well-being, you have a better chance of having some or all of your expenses covered. 

Factors Influencing the Number of Covered Treatment Stays

addiction treatment with ppo

There are a few important factors that may influence your PPO addiction treatment coverage. These include:

  • Whether there are appropriate providers in your network, or you have to use out-of-network programs, which may cost you more.  
  • Whether the treatments, programs, medications, and other care are considered medically necessary. For example, a medical detox may be approved, while acupuncture or equine therapy may not.
  • Whether you have a pre-existing condition that affects your coverage. Some insurance companies have extensive terms that must be met before coverage kicks in.
  • Whether you have met your annual deductible. Your insurance will only start once this amount has been paid toward your treatments. 

Navigating Multiple Treatment Stays with PPO Insurance

Each insurance plan differs in what it will allow, and that includes multiple stays in rehab. Some may require stays in in-network facilities, while others may limit the number of stays they will cover within a specific timeframe.

To learn what your insurance will cover you can call the number on the back of your insurance card to speak with a representative about your options or log in to the insurance company’s online portal to find out what your options are. In some cases, the treatment center will be able to call the insurance company on your behalf to find out information, with your permission. 

At WhiteSands we know that navigating bureaucracy and dense policy text can be difficult at the best of times, and if you are living with a substance use disorder, trying to get help can be overwhelming. If you don’t feel confident speaking with your insurance company or aren’t sure what to ask, you can always call WhiteSands Treatment for assistance. We are well-versed in many types of insurance, and, with your approval, we can talk to your insurance company on your behalf, and explain their policies to you in plain language that is easy to understand. 

The Role of Continuous Assessment in PPO Coverage

Although important, rehab is only the first step in the recovery process. Lifelong sobriety often involves aftercare, relapse prevention, and ongoing treatments that can last for months, years, or even a lifetime. Unfortunately, in some cases, insurance companies put strict time limits on the number of days a person can stay in each level of care. 

Some may require additional assessments after some time, to assess whether your needs remain the same, are still medically necessary, and coverage can continue. Each insurance company has different rules, and it will depend on your policy. 

Maximizing Your PPO Benefits for Addiction Treatment

The best ways to get the most out of your insurance plan while in addiction treatment include taking steps like:

  • Carefully review your insurance policy documents, so you understand what is and what is not covered by your insurance. 
  • Empowering yourself by learning about in-network vs. out-of-network coverage, learn your coverage limits, copay and deductible amounts
  • Keeping detailed records every time you speak to your insurance provider, including the date of contact and who you talked to, in case of future disputes over coverage
  • Checking whether you need prior authorization or documentation from your primary care physician
  • Calling the insurance provider directly to learn more about your coverage, and asking for a list of in-network providers

How WhiteSands Treatment Works with Your PPO Plan

At WhiteSands, we are more than happy to work within the constraints of your out-of-network health insurance as much as possible to maximize your insurance coverage. Each of our patient’s care plans is tailored to best suit their needs, and although we always put your health and comfort first, we will also consider your financial situation and resources. All of our inpatient and outpatient services are customizable, so we can work with you to build a plan that will help you overcome addiction without breaking the bank. 

To learn more about our detox services and our inpatient and outpatient programming, or to verify your insurance coverage, please call us at (877) 855-3470. We are happy to answer all of your questions, even if you’re not sure whether you’re ready to start treatment. We are here for you. 

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.

About the Author

Jackie has been involved in the substance abuse and addiction treatment sector for over five years and this is something that she is truly eager about. She has a passion for writing and continuously works to create informative pieces that not only educate and inform the public about the disease of addiction but also provide solutions for those who struggle with drug and alcohol abuse.