When you look at your insurance plan, you might notice an acronym at the end, like PPO or HMO. This lets you know what kind of insurance plan it is, so you’ll have some idea of how important coverage features work. HMO healthcare plans operate in a specific way when it comes to the provider network, but they are still long-term insurance plans. That means you can rely on them to cover the 10 essential health benefits required by the Affordable Care Act (ACA), including mental health and substance use treatment.^{1, fifth bullet}

This guide will help you understand HMO insurance coverage and how it’s different from other types of insurance, so you can get the care you need to break free from substance use.

What is an HMO?

To understand a Health Maintenance Organization (HMO) plan, it’s important to understand insurance provider networks. Every insurance plan has a group of facilities, doctors, and hospitals that agree to treat plan members for a lower price than usual.^{2, p. 1 What’s a Provider Network} This group is the plan’s provider network.^{2, p. 1 What’s a Provider Network} In return for lower prices, the health insurance plan refers its members to use these doctors and facilities.^{2, p. 1 What’s a Provider Network}

When you use providers within the network, you’ll get the most benefit from your insurance and pay less of the cost yourself.^{2, p. 2, Why do some plans…} Some insurance plans provide limited coverage for out-of-network providers, and some have no coverage, so you have to pay the full cost of out-of-network care yourself.^{2, p. 2, Why do some plans…}

HMO coverage is a type of plan that generally provides no coverage outside the provider network.^{3, Types of marketplace plans} That means if you choose a doctor, hospital, or substance use treatment facility that’s not part of the network, you have to pay the full cost of treatment yourself.^{3, Types of marketplace plans} The only exception is if you need emergency care—in an emergency, the insurance plan will likely cover out-of-network care.^{3, Types of marketplace plans}

HMO medical insurance has a variety of benefits. Plans often cost less per month than other types of plans, and the right HMO can have a broad network that makes it easy to find the care you’re looking for within the provider network.^{4, Health Maintenance Organization (HMO)} They also focus on preventive care and wellness, and you choose a primary care physician that coordinates your care and provides referrals to specialists.^{4, Health Maintenance Organization (HMO)}

What are HMO Coverage Levels and Plans?

You can find HMO plans at every level of coverage and at almost any health insurance provider. HMOs are also available in every state across the country. However, if you travel often, you may choose a different type of plan since the insurance provider network is likely to be based in your local area.^{3, Types of marketplace plans}

What will HMO insurance cover for substance use treatment?

Like all long-term plans, HMO insurance will provide at least some coverage for substance use treatment. Each person’s treatment program will be different, depending on their specific needs. You’ll want to work closely with your doctor to create the right treatment plan for you.

Some of the most common treatment options include:^5,6

Inpatient rehab. During inpatient treatment, you will live at the treatment center full-time and receive around-the-clock care. This safe and structured environment will allow you to begin the process of recovery and work on underlying mental health issues. You will get a combination of group and individual therapy, which will help you identify the root issue and develop a customized treatment plan that addresses your unique needs.
Outpatient rehab. Outpatient care is a few hours a week of therapy, counseling, or activities. It can be a starting point for treatment or a follow-up after you graduate from inpatient treatment. This kind of treatment allows you to maintain your normal schedule while getting the help you need. Outpatient sessions typically focus on substance abuse education, relapse prevention, stress management, communication skills, and goal setting.
Intensive outpatient programs (IOP). Intensive outpatient treatment (IOP) is an option for those who need more care than what is offered in standard outpatient treatment, but who do not require the 24/7 care offered in inpatient treatment. IOP generally consists of 3 hours of treatment per day, 3-5 days per week. IOP programs offer a variety of courses and treatments that can address the underlying causes of addiction.
Partial hospitalization programs (PHP). PHPs offer a similar treatment intensity and daily structure to that of inpatient/residential programs while also providing access to the outside world. This allows patients to continue building their support system while receiving treatment. PHPs offer a wide range of services, including individual and group therapy, family meetings, medical services, and treatment for comorbid mental health disorders.

Different HMO plans will have different requirements and limits on substance use treatment coverage, so you’ll want to get the details of your insurance before you commit to treatment. You can call your insurance company directly or contact American Addiction Centers (AAC) anytime by online chat, phone, or filling out the form below. Our admissions navigators will verify your insurance in just a few minutes while they chat with you and can answer your questions about rehab as well.

Does HMO Insurance Cover Mental Health Treatment Facilities?

If you struggle with both your mental health and substance use, you might feel especially isolated and alone. However, it’s a common struggle. Around 50% of those who battle substance use also have a mental health diagnosis, which is known as a co-occurring condition.^{7, second paragraph} What’s most important is to get treatment for both your mental health and substance use at the same time. Research shows that this integrated treatment has a far better success rate than treating only one or the other.^{8, first paragraph}

Will your HMO insurance coverage help you with both mental health and substance use treatment? It will because both conditions are part of the 10 essential health benefits the ACA requires long-term insurance plans to cover.^{1, fifth bullet} Different insurance plans may have specific requirements or details that need to be followed to get coverage, so be sure to check your insurance before you commit to a program. You can call the insurance company directly or reach out to AAC anytime 24/7. We’re here to help you break free of substance use and live the life you truly want.

How Long Does HMO Insurance Cover Rehab?

How long is rehab? It’s a common question, and no answer is right for everyone. Research shows that it takes at least 90 days for most people to make a significant change in their substance use habits, including quitting.^{9, fifth point} That’s why many treatment programs are three months long.

However, your treatment process may be longer and might include multiple treatment options, like inpatient rehab followed by an outpatient program. What’s most important is that you follow it through all the way to completion. It’s common to want to stop when you start feeling better, but only by completing the full treatment process do you give yourself the best chance of long-term recovery.

What if my HMO policy does not cover rehab?

As you review your treatment options, you might find that a treatment center you’re interested in isn’t part of the network of your HMO plan. That means you’ll have to pay the full cost of rehab yourself. Or, you might discover your HMO plan covers only part of the cost, and you have to pay a portion out-of-pocket. Don’t let the financial situation keep you from getting treatment, though. There are many ways to pay for rehab, and your insurance is only part of the picture.

For example, some programs offer scholarships for your portion of the fees, or you might be able to work out a payment plan. Some people borrow money from family and friends for treatment. What’s most important is to get the treatment you need right away. There’s never a perfect time for rehab, and there are also long-term health and legal consequences to substance use. You want to break free now before it’s too late.

HMO In Network vs. Out of Network Rehab Centers

As we mentioned earlier, the biggest difference between an HMO and some other health plans is that it generally doesn’t pay for care outside the provider network unless there’s an emergency.^{3, Types of Marketplace plans} That means if you want to take advantage of your health insurance plan to pay for the cost of treatment, you’ll want to find a program that’s part of the network for your HMO rehabilitation coverage. If you can’t, don’t panic—there are many ways to pay for rehab, and getting the right care is worth it.

Check HMO Insurance Coverage for Rehab

Breaking free from substance use is courageous, and it takes the right kind of help to be successful in the long term. If you have HMO rehab insurance, you’ll want to make sure the treatment program you choose is part of the plan’s provider network if possible.

To get the details on what treatment facilities are covered by your plan, you can call the insurance company, or you can contact AAC at any time, day or night. Our admissions navigators are available by online chat, over the phone, or by filling out the form below.

You deserve a life free of substance use so you can chase your dreams and have a life you love. To take the first step, contact us today.

Does HMO insurance cover Alcohol and Drug Rehab?