A recent survey conducted by Bend Financial revealed that 56% of Americans feel “completely lost” when it comes to health insurance, with many confused about the various types available.
This brings up an important question: When it comes to addiction treatment, which is better, PPOs or HMOs, and can you access the care you need with your current insurance?
The answer isn’t straightforward. Insurance policies and their coverage can differ significantly, even among similar categories. PPOs and HMOs, while appearing alike, have crucial differences that are essential to grasp, particularly if you may require addiction treatment coverage from either option in the future.
PPOs vs. HMOs Summarized
HMOs are typically more affordable but restrict you to a specific network of healthcare providers. Generally, you’ll need a referral from your primary care provider to see specialists, including those specializing in addiction treatment.
PPOs are usually pricier but provide more flexibility in choosing where to receive treatment, both in and out of network. With PPOs, you can often see specialists, including addiction treatment professionals, without needing a referral.
It’s worth noting that even within the same type of plan, specifics can vary greatly. To understand your coverage, contact your insurance provider or consult with Ark Behavioral Health for a cost estimate related to your treatment program.
A Closer Look at PPOs
PPO stands for Preferred Provider Organization. This type of plan includes a network of healthcare providers, including doctors and hospitals, who offer services at reduced rates. While PPO plans allow you to access care from outside this network, higher out-of-pocket costs may apply.
Although PPOs typically have higher monthly premiums compared to HMOs, many prefer them for the increased flexibility they provide. With PPOs, you can usually refer yourself to specialists without needing a referral from your primary care physician. In fact, maintaining a primary care doctor isn’t necessarily required, so you can see various doctors as needed.
PPOs are especially beneficial for people who travel frequently, as they allow you to receive care anywhere, not just in your local area. Generally, this type of plan is widely available at nearly every coverage level across almost all states. According to a study by KFF (formerly known as The Kaiser Family Foundation), PPOs are the most popular type of health insurance, covering about 49% of workers in the U.S., compared to 12% for HMOs.
A Closer Look at HMOs
HMO stands for Health Maintenance Organization. Similar to PPOs, HMOs have a network of providers who offer services at reduced rates. However, while PPO plans permit some out-of-network visits, HMOs tend to enforce stricter limitations, focusing more on preventive care.
Typically, HMOs require you to have a primary care physician who will coordinate your care and facilitate referrals to see specialists, including those for addiction treatment. Consequently, your options for specialists may be more restricted.
The benefit of HMOs is that they usually offer lower monthly premiums compared to PPOs, which can be appealing for individuals who primarily stay in one locale and do not travel frequently.
Like PPOs, HMO plans are often available at many coverage levels through various providers in every U.S. state.
Do PPOs Cover Addiction Treatment Services?
The Affordable Care Act of 2010 (ACA), also known as Obamacare, significantly changed how insurance companies handle mental health and behavioral healthcare, specifically substance use treatment. Under the ACA, all long-term health insurance plans must include mental healthcare and addiction treatment services as essential health benefits.
This means that PPOs are required to cover addiction treatment services, and due to their inherent flexibility, you typically have more options regarding which treatment provider to choose, although you may save costs by staying in-network.
PPO plans often also grant you the freedom to seek addiction services without needing a referral from a primary care physician.
Do HMOs Cover Addiction Treatment Services?
HMOs must, like PPOs, adhere to federal laws that mandate the inclusion of addiction treatment services as essential benefits. However, these plans generally offer less flexibility compared to PPOs.
While a PPO can allow you to choose between in-network and out-of-network providers, HMO plans restrict you to their designated provider network for coverage.
Additionally, HMO policies typically require that you go through your primary care physician to access addiction treatment services. Thus, you will need to contact your doctor, possibly make an appointment, and obtain a referral.
Nonetheless, HMO plans can make treatment more affordable than paying out-of-pocket, depending on your circumstances.
Types of Addiction Treatment Covered
Your health insurance can cover a variety of recognized, evidence-based addiction treatment services in both inpatient and outpatient settings. Commonly covered services include:
- Medical Detox: Close supervision and support to help clients manage withdrawal symptoms after stopping drug or alcohol use.
- Behavioral Therapies: Talk therapies like cognitive behavioral therapy (CBT) that help identify and modify harmful thoughts and behaviors related to substance use.
- Psychoeducation: Informative sessions that educate clients about addiction, recovery, and relapse, equipping them to make informed decisions in the future.
- Medication-Assisted Treatment (MAT): This method combines FDA-approved medications like naltrexone, methadone, and buprenorphine to treat opioid or alcohol use disorders.
- Dual Diagnosis Treatment: Specialized services offered by rehab centers to address substance use disorders alongside co-occurring mental health issues such as anxiety or depression.
- Peer Support Groups: These groups provide a platform for individuals facing addiction to connect, share experiences, and develop social skills.
- Aftercare Coordination: This service organizes long-term recovery resources, including self-help groups and employment assistance.
Keep in mind that addiction recovery is a lifelong journey, and you may benefit from various treatment services over time, depending on your unique needs and experiences.