Optima Health Alcohol And Drug Rehab Insurance Coverage

Optima Health is a Virginia-based health insurance provider that offers employer-sponsored health insurance coverage as well as individual health insurance. Optima Health may cover behavioral health services and substance use disorder treatment through its HMO, POS, or PPO plans.

Optima Health does offer addiction treatment coverage under its behavioral health benefits. The total amount that patients pay will depend on the plan that they purchased or received through their employer.

All Optima health plans do come with a deductible, which may need to be met before the insurance company covers treatment.

As a result, patients should consider the following when considering how to pay for substance abuse treatment:

  • Copays
  • Coinsurance fees
  • Deductibles
  • Maximum out-of-pocket requirements
  • Prescription drug plans

Depending on the rehab facility you’re considering for treatment, you may have help available in covering some of these costs. There are more than 500,000 Optima Health members, so the insurance carrier is widely accepted.

Optima Health Coverage For Massachusetts Drug And Alcohol Rehab

Optima Health provides substance use disorder treatment, mental health treatment, and dual diagnosis treatment coverage for people whose doctors determined that it was medically necessary.

The out-of-pocket requirements to be met will be determined based on if the patient decides to have inpatient treatment, outpatient treatment, in-network treatment or out-of-network treatment.

Using Optima Health To Pay For Addiction Treatment

Before Optima Health will cover the full cost of addiction treatment, the deductible must be met for the calendar year (in most cases). After policyholders meet the deductible, they may have to pay coinsurance or a copayment for treatment services until they reach their maximum out-of-pocket requirements.

Optima Health usually covers:

  • 5 to 30 percent of the costs of inpatient rehabilitation after meeting the deductible
  • Up to 100 percent of the cost of inpatient treatment on the OptimaFit Catastrophic Plan

Policyholders may need to pay:

  • Between $250 and $600 daily for copays up to a maximum of between $1,000 and $2,400 based on the specific policy.
  • Coinsurance between 20 and 40 percent of the cost of rehabilitation after the deductible and up to the out-of-pocket maximum.

Outpatient treatment is handled differently, with copays ranging between $10 and $40 and coinsurance ranging from 5 to 20 percent. Employer-sponsored plans may have copays ranging from $150 to $300 per visit to an outpatient treatment facility and coinsurance as low as 0 percent or as high as 40 percent after the deductible is met.

Do I Have To Stay In-Network To Use Optima Health For Drug Rehab?

You do not need to stay in-network to use Optima Health coverage, but your coverage will be reduced if you choose an out-of-network treatment provider. Those with HMO plans need to visit in-network providers, but those who have PPO and POS plans may be able to get coverage for out-of-network providers at a higher rate.

What Will Be My Out-Of-Pocket Costs For Rehab?

Your out-of-pocket costs for rehab will depend on the kind of plan you have through Optima Health.

Optima Health offers several plan tiers, including:

  • Gold
  • Silver
  • Bronze

Gold plans have a higher premium, but they also lower the out-of-pocket costs you pay. Bronze plans are low-cost plans that have higher out-of-pocket rates.

You also need to know if you have a:

  • PPO plan—Preferred provider organization plan, which allows you to choose out-of-network providers if you choose. The care will be at a greater cost.
  • POS plan—The point-of-service plan puts together the best benefits of a PPO plan and an HMO plan to create a plan with good in- and out-of-network coverage.
  • HMO plan—A health maintenance organization plan allows you to see any health provider who is within your network. Generally, you will not need a referral.

The cost you will pay for your care will depend on which level of insurance you have as well as the type of policy. At Spring Hill Recovery Center, we’re happy to verify your plan and discuss the costs you’ll have for rehab. We can also discuss options such as seeking scholarships, grants, or using a sliding-scale policy to pay for treatment.

How Do I Find A Massachusetts Rehab Center That Accepts Optima Health?

You can visit the Optima Health website and look at the Community Mental Health Rehabilitation Services offered. You can also use the “find a provider” tool on the website or speak with our team of addiction specialists at Spring Hill Recovery.

Is Medical Detox Covered By Optima Health?

Medical detox may be covered by Optima Health. Your specific plan will detail coverage. Because detoxification is a vital part of recovery for many people who have a chemical dependency, most health insurance plans cover it. Whether you have a prescription drug plan may also affect the cost of medical detox.

Does Optima Health Cover Outpatient Treatment?

Outpatient treatment may be covered by your Optima Health plan. Outpatient services range in length and format, but offer flexible treatment options for people who cannot attend inpatient treatment. Coverage for outpatient rehab programs through Optima may require you to provide prior authorization or proof of medical necessity.

Is Partial Hospitalization Covered Through Optima Health?

Day Treatment/partial hospitalization treatment may be covered if a medical provider believes that this service is needed. Optima Health members may be required to fill out a form to meet prior authorization for PHP programs.

Is Massachusetts Intensive Outpatient Treatment Covered Through Optima Health?

Through the Community Mental Health Recovery Services aspect of the Optima Health Plans, intensive outpatient treatment and intensive in-home treatment are offered. Therapeutic day treatment rehab services are also available.

Does Optima Health Cover Sober Living?

Sober living homes offer a safe, alcohol- and drug-free environment for people recovering from addiction. Optima Health may not provide coverage for sober living. Sober living costs can still be mitigated by seeking grants, scholarships, and other support through your chosen treatment facility.

Does Optima Health Cover Medication-Assisted Treatment?

All of Optima Health’s insurance plans vary significantly, so the range of coverage is difficult to cover easily. Most of the time, patients who are in need of medication-assisted treatment will fill their prescriptions under their prescription benefits.

The cost of prescription drugs will depend on the medications they are prescribed and their current prescription benefits. Depending on the plan, the cost of MAT may be anywhere from $5 per prescription up to 35 percent of the drug’s cost.

Are Methadone Costs Covered By Optima Health?

Optima Health offers different coverage for medications in their employer plans and OptimaFit plans, Medicaid and Medicare. The coverage that you receive will be based on the plan that you have as well as the prescription drug coverage that is provided.

Will Optima Health Cover Suboxone Therapy?

Suboxone therapy is common for those who have struggled with opioid addiction. It can help reduce the likelihood of using in the future. Suboxone may be available and covered by your insurance through the prescription coverage plan.

Verifying Your Massachusetts Optima Health Coverage

At Spring Hill Recovery, we will help you verify that your insurance covers your care here with us. We offer our services throughout the northeastern United States and New England.

We have care options available for residents coming to us from the following states, as well as many more:

Our team is here to help you find out about your coverage and to help you find ways to cover the cost of treatment when your insurance doesn’t cover all of it.

We have options for financing that we can discuss with you if you’re concerned about the cost of your care. Reach out to Spring Hill today, and we will help you validate your insurance carrier coverage and get the support you need through alcohol and drug treatment services.

  1. Optima Health – Added Benefits for Optima Family Care https://www.optimahealth.com/plans/family-care/added-benefits
  2. Optima Health – Prescription Drug Lists and Formularies https://www.optimahealth.com/members/manage-plans/prescription-drug-lists
  3. Optima Health – Prior Authorization Forms and Policies https://www.optimahealth.com/providers/authorizations/medical/prior-authorization-forms
  4. Substance Abuse and Mental Health Services Administration—Buprenorphine https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/buprenorphine

Written by Spring Hill Recovery Editorial Team

© 2024 Spring Hill Recovery | All Rights Reserved

* This page does not provide medical advice.

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