Using Out-Of-Network Benefits To Go To Rehab

Recent laws have made addiction treatment more accessible for more Americans. This includes the Affordable Care Act (ACA), passed in 2010, and the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008, a federal law that prevents health plans from imposing barriers on access to mental health and substance abuse care that don’t apply to other medical or surgical benefits.

However, this doesn’t mean that all treatment options are covered by insurance, or covered equally. Different health insurance plans offer varying levels of coverage and out-of-pocket costs, and costs aren’t the only factor to consider when choosing the best treatment option for yourself.

Understanding the basics behind in-network versus out-of-network providers, and why people might choose one over the other, can help you make an informed decision when it comes to your care. Out-of-network rehab centers do tend to cost more, but there are reasons why someone may choose this option, including being able to be more choosy with their care or attend a specialized program.

Below, we’ll explore the benefits of using out-of-network benefits to go to rehab, the costs associated with out-of-network care, and the steps to take to use out-of-network benefits.

Out-Of-Network Vs. In-Network: What’s The Difference?

You may have heard the terms “in-network” and “out-of-network” in reference to health insurance and treatment providers. Your insurance carrier has a list of in-network providers (hospitals, physicians, therapists, etc.,) that it has pre-negotiated service costs with. It also may offer some coverage for out-of-network providers. People can generally expect to pay more when using out-of-network providers but will have more options available.

Out-Of-Network Rehab Benefits

You or a loved one may be wondering, Why choose an out-of-network provider when an in-network provider is most likely cheaper? Below we’ll look into some benefits of choosing an out-of-network provider.

A Broader Range Of Treatment Options

One reason people seek care at out-of-network addiction treatment centers is to have access to a wider range of treatment options. Sometimes, in-network providers don’t offer a specific program or service that would most benefit the person’s recovery. For example, someone with a substance use disorder (SUD) and bipolar disorder would benefit most from dual diagnosis care, as treating both disorders at the same time is proven to be the most effective approach. If this person’s in-network providers don’t offer this treatment option, it probably makes more sense to go out of network for care.

More Options For Locations And Amenities

People may also want to attend a specific addiction program in a specific area, like on the beach, in the mountains, or near a loved one. Using out-of-network benefits means you’ll have more rehab centers to choose from overall.

This also applies to the amenities that rehab centers offer, such as an onsite fitness center, spa, movie theater, meditation room, or swimming pool.

More Appropriate Treatment Length

While insurance carriers may provide only a few in-network options, limiting what services the policyholder receives, where they attend treatment, and the amenities available, they also may place a time constraint on how long they’ll cover treatment. This may cause people to stop receiving treatment before they are ready to be without support, increasing the risk of relapse.

Overview Of Out-Of-Network Costs

In some cases, insurance plans offer specific out-of-network (OON) costs, including deductibles, coinsurance, and out-of-pocket maximums. You may also be required to be preauthorized for treatment for your insurance company to provide OON coverage.

Every insurance plan is different, and understanding your benefits can be confusing. It is always recommended that you speak with an insurance representative to learn the specifics of your plan. Spring Hill also offers free verification of insurance benefits.

OON Deductible And Coinsurance

An out-of-network deductible is the amount you pay for services from providers not in your insurance network before your insurance starts covering costs. For example, if your OON deductible is $2,000, you’ll need to pay that out of pocket before insurance kicks in.

Coinsurance is the percentage of medical costs you’re responsible for after insurance coverage begins, and many plans offer a separate, higher coinsurance rate for out-of-network treatment. If your plan has a 30% OON coinsurance, you’d pay 30% of the bill while your health insurance pays the rest.

OON Out-Of-Pocket Maximum

An OON out-of-pocket maximum refers to the limit on how much you pay for covered medical services from out-of-network providers in a given policy period, usually a calendar year. Once you reach this limit, your insurance will pay for 100% of eligible out-of-network healthcare costs.

Out-of-network maximums are also typically separate from in-network out-of-pocket maximums and are often significantly higher. Your OON deductible counts toward this maximum, as do your copays and coinsurance. However, charges above the provider’s standard rates may not apply, leaving you responsible for those additional costs.

OON Pre-Authorization Requirement

Out-of-network pre-authorization is a process where insurance carriers review and approve a medical service or treatment from an OON provider before the policyholder receives care. This step determines whether the service is medically necessary and eligible for coverage under an insurance plan. Without pre-authorization, an insurer may deny the claim, leaving you fully responsible for the costs.

OON pre-authorization is often required for substance abuse treatment. The process typically involves the out-of-network provider submitting documentation, like treatment plans or medical history, to the insurer for review.

Using Out-Of-Network Benefits For Addiction Recovery

If you plan on using your health insurance benefits to help cover the cost of treatment, you’ll want to verify your benefits before beginning treatment if possible. For OON treatment providers, you will most likely need to file claims with your insurance provider as they come in. Be sure to ask for any help you need along the way from your insurance provider.

Verify Benefits And Find A Treatment Provider

Knowing what health insurance will cover is often the first step in the addiction recovery journey. You can contact your insurance company, either online or by phone, to ask about covered services, pre-authorization requirements, and out-of-pocket costs, including out-of-network deductibles, copays, etc. For out-of-network providers, ask about reimbursements and expenses that may not count toward the OON maximum.

If you plan on using an in-network provider, many insurance companies offer an online tool where you can filter options by specialty, location, and client reviews.

Because you have more freedom when using an out-of-network provider, you can search online for a treatment center that appeals to you and offers the services, amenities, location, etc., that you have in mind for your recovery.

File Claims

Filing a claim is the process of requesting reimbursement or payment from your insurance company for services. While in-network providers usually handle claims directly, out-of-network claims often require you to file them yourself.

To file a claim, gather essential documents, including an itemized bill from the treatment provider, proof of payment, and a completed claim form from your insurance company. Include the treatment provider’s information, the service dates, and treatment descriptions. Submit these documents to your insurance company. After submission, monitor the claim’s status and respond promptly to any requests for additional information.

Ask For Help

Navigating out-of-network benefits can be complex, but asking for help along the way can maximize your coverage and minimize unexpected costs. Customer service representatives can explain the claims process and help you understand reimbursement policies. Additionally, treatment centers may be able to help you determine what your insurance covers and doesn’t cover.

Addiction Treatment At Spring Hill

Spring Hill Recovery Center is in-network with many insurance providers, including Aetna, Blue Cross Blue Shield, Humana, and others. However, if we are out of network with your insurance, we can help you determine what your coverage and estimated out-of-pocket costs will be. Call to learn more—we are always happy to help!