Drug addiction and Substance Use Disorders (SUDs) are among the most pressing issues of our times. Prescription drug overprescription, the ongoing opioid epidemic, and rising SUD rates across different demographics and occupations paint a bleak picture. Worse still, SUDs are truly complex to address, often requiring lengthy, specialized, and ultimately costly rehab services. An Intensive Outpatient Program (IOP) alone, best suited for moderate cases, might extend beyond 3 months, becoming prohibitive for many. So, you may rightfully wonder if health insurance covers IOP in Parkersburg WV – or other rehab programs, for that matter.
At Harmony Ridge Recovery, we understand just how complex health insurance rehab coverage can seem. As pioneers among rehab centers in West Virginia, it’s our mission to deliver both excellent services and valuable information. In this article, we’ll focus on the latter, hopefully offering you peace of mind as regards financing rehab.
Why Does Health Insurance Coverage Differ So Significantly?
Now first, we should begin to explain just why the issue of rehab coverage is as complex as it is. Please bear with us for a few short paragraphs, and it will all soon make sufficient sense.
The first factor comes in the form of federal laws and mandates.
The MHPA (Mental Health Parity Act) of 1996 included ample protections, but ones that did not explicitly extend to SUDs. The MHPAEA (Mental Health Parity and Addiction Equity Act) of 2008 made progress in that regard, but still “does NOT require large group health plans or health insurance issuers to cover [rehab] benefits.” Rather, what it does is it “prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits”.
And yet, it’s common that insurance covers IOP in Parkersburg WV and across the nation. That’s because ACA (the Affordable Care Act) enhances MHPAEA, as CMS (Centers for Medicare & Medicaid Services) covers above:
“The Affordable Care Act builds on MHPAEA and requires coverage of mental health and substance use disorder services as one of ten EHB categories in non-grandfathered individual and small group plans.”
Still, even in that quote you may spot a factor of complexity. Even ACA does not mandate rehab coverage in all cases, but only in common, widely used plans.
An Abundance Of Plans
This abundance of healthcare plans also complicates things further. Every plan will differ from the next in exact scope and purpose, including coverage for rehab. Plans may differ in what they deem necessities, and in exactly how they define necessities. Most notably, they will also differ in terms of coverage amounts; copayment thresholds, deductibles, you name it.
For some simple examples of this across major health insurance providers, consider the following:
- Peia offers four Preferred Provider Benefit (PPB) plans; Plans A to D. In addition, it offers a two-part Health Plan, consisting of Health Maintenance Organization Plans A and B, and Preferred Provider Organization. Such insurance covers IOP in Parkersburg WV and beyond, but coverage varies substantially.
- Humana offers four Medicare plans for drug rehab specifically; Medicare Part A to D. While D covers prescription drugs specifically, the others focus on specific rehab costs. As for individual plans, for 2022 alone, Humana has announced an additional 72 plans among its offerings.
- TRICARE initially included 3 plans; Prime, Extra, and Standard. Today, TRICARE offers 11 distinct plans. These don’t differ as substantially in terms of coverage, but still present different terms to review.
As such, most articles on health insurance coverage need to deal with relative generalities. It’s simply impossible to cover every case, especially across states, which makes carefully reviewing your plan a necessity.
Finally, beyond federal laws and plan variety, come state differences. Yes, federal law does offer some basic uniformity in this regard, including:
- Basic coverage for essential health benefits
- Protections, such as upper limits on out-of-pocket expenses or protections against being charged more based on health or gender
- Levels of coverage, which the ranks of plans will reflect in each state’s health insurance marketplace
However, states do retain control over which and how many health insurance providers can sell on their marketplace. In addition, they can determine which treatments fall under essential health benefits. As such, that your insurance covers IOP in Parkersburg WV doesn’t mean it will cover similar programs in different states.
WebMD summarizes this key factor as follows:
“Although the law set the 10 general categories that essential health benefits must cover, it did not list all the services that fall under each category. Each state is allowed to identify an existing plan as a benchmark for the essential health benefits. As a result, health plan benefits vary from one state to another.”
How Much Does Rehab Cost Without Health Insurance?
Of course, the reason why health insurance is so significant in the context of rehab is, simply, rehab’s prohibitive costs. Those too can offer quite significantly, depending on such factors as:
- The exact duration of one’s programs; different cases of addiction require very different journeys to recovery. The duration of each program should rely on the individual’s progress, not universal durations.
- Pharmacotherapy, and clinical and psychiatric services; underlying mental health disorders are quite common in SUDs. Specialized care for such cases and severe cases of SUDs come with higher total costs.
- The local addiction treatment market; beyond state-side rehab coverage, individual addiction treatment providers’ prices will also differ significantly. From service quality and facility luxuries to local competition, final costs will inevitably vary.
Thankfully, however, health insurance does tend to partially or fully cover rehab costs. In our local case, it’s very likely that your insurance covers IOP in Parkersburg WV to some decent extent. This is indeed fortunate, as rehab costs with no insurance coverage can be very steep. For reference, here we may cite the typical full costs of rehab that DrugHelpline provides:
- Drug Detox (30 days): $240–$850 per day
- Residential Treatment (duration varies): $5,100–$80,000
- Intensive Outpatient (30 days): $3,100–$10,000
- Outpatient Care (3 months): $1,450–$10,000
As you can see, not everyone can cover such expenses out of pocket. IOP specifically tends to cost much more than its less intensive outpatient counterpart, making health insurance coverage invaluable.
Major Health Insurance Providers
With the above in mind, here we may cover the basics of major health insurance providers, including:
- Humana Insurance
- Blue Cross Blue Shield
- TRICARE Insurance
- PEIA Insurance
Alongside a note on the Family and Medical Leave Act (FMLA), which often enters this discussion, here we may explore the fundamentals of each. If you’d rather skip this section, please rest assured that Harmony Ridge Recovery and many of our West Virginia peers accept all of the above.
Should you need any additional assistance not covered here, please feel free to contact us. Our teams are available 24/7 at (855) 942-3797, and will happily help review your health insurance plan and financing options.
#1 Blue Cross Blue Shield
One of the largest US health insurance providers, Blue Cross Blue Shield offers coverage to more than 100 million Americans. Given its expansive scope, Blue Cross Blue Shield insurance covers IOP in Parkersburg WV in the vast majority of cases.
Blue Cross Blue Shield plans are structured in a typical way:
- Bronze plans, which only cover in-network or preferred network providers.
- Silver plans, which typically also don’t cover out-of-network services but come with more benefits and higher deductibles.
- Gold plans, which may sometimes cover out-of-network services and require coinsurance percentages.
- Platinum plans, which tend to cover both in-network and out-of-network services – albeit with different deductibles and coinsurance percentages.
For additional information, we have a page dedicated to Blue Cross Blue Shield if you would like to know more.
#2 PEIA Insurance
In contrast, PEIA is funded by the state of West Virginia. As such it has a much broader scope, but it does explicitly cover rehab costs. In fact, prescription drug coverage was included since its establishment in 1971, as the Agency notes:
“PEIA was established under the Public Employees Insurance Act of 1971, to provide hospital, surgical, group major medical, prescription drug, group life, and accidental death and dismemberment insurance coverage to eligible employees; and to establish and promulgate rules for the administration of these plans.”
Of course, this also means that PEIA insurance has the explicit eligibility requirement of being an “active employee of the State of West Virginia [or] various related State agencies and local governments”. If you do meet this criterion, your PEIA insurance covers IOP in Parkersburg WV and broader West Virginia.
If you’d like to know more about this insurance provider, you can also visit our page dedicated to PEIA Insurance.
#3 TRICARE Insurance
TRICARE insurance is similarly specific in its application, in comparison with broader health insurance providers. TRICARE is part of the DHA (Defense Health Agency) and caters to active military personnel, military retirees, and their dependents. It does cover rehab, making it a common provider to cover rehab for veterans.
A peculiarity we must highlight here requires a specific term; Other Health Insurance (OHI). As we’ll see next, this term refers to other health insurance you may have other than TRICARE. In this context, we must note that TRICARE only begins to cover rehab expenses after most OHI. By law, the few exceptions to this are:
- TRICARE supplements
- State Victims of Crime Compensation programs
- Federal government programs
For more information on this health insurance provider, you may visit our page on TRICARE Insurance.
#4 Humana Insurance
Another very notable health insurance provider is Humana Insurance. Not all of Humana’s plans offer rehab coverage, but the ones that do are now largely synonymous with Medicare. For this reason, and given its extensive coverage, Humana is a common health insurance provider for drug rehab for seniors.
Humana insurance covers IOP in Parkersburg WV and beyond, but in different ways depending on each plan:
- Medicare Part A plans cover hospital care costs.
- Medicare Part B plans cover doctors’ expenses. Together, Part A and Part B make up “Original Medicare”.
- Medicare Part C plans offer all the benefits of Original Medicare, thus covering both hospital care costs and doctors’ expenses.
- Medicare Part D plans cover prescription drug-related services and their costs.
In addition, Humana offers individual plans within each Part. Such plans will cover rehab costs, but come with different premiums, deductibles, and so forth. So, you may want to visit Humana’s Medicare coverage page to explore each plan’s exact features.
For more general information on this provider and rehab coverage, you may also explore our page on Humana Insurance.
What About FMLA?
Finally, here we may make a brief note on FMLA specifically. The acronym comes from the Family and Medical Leave Act, a federal law passed in 1993. The law does not constitute health insurance in itself; rather, it enshrines into law that:
- Employees may take “up to 12 weeks of unpaid, job-protected leave per year”, and that
- “[employees’] group health benefits be maintained during the leave”.
Thus, FMLA will not cover rehab costs. Rather, it will ensure you cannot be fired while you take your leave, while your employers’ healthcare benefits do.
So Does FMLA Apply to Rehab at All?
Notably, FMLA does not explicitly cover drug rehab, but it can still cover rehab costs. Put differently, if your employers’ insurance covers IOP in Parkersburg WV and beyond, FMLA can apply it. That’s because FMLA specifically covers, according to the DOL:
- The birth of a child and to care for the newborn child within one year of birth;
- The placement with the employee of a child for adoption or foster care and to care for the newly placed child within one year of placement;
- Caring for the employee’s spouse, child, or parent who has a serious health condition;
- A serious health condition that makes the employee unable to perform the essential functions of his or her job; or
- Any qualifying exigency arising out of the fact that the employee’s spouse, son, daughter, or parent is a covered military member on “covered active duty”.
What constitutes a “serious health condition” is what enables rehab coverage, as it includes:
- Memory disorders
- Disorders such as severe depression, severe bipolar disorder, and schizophrenia
- Post-traumatic stress disorder (PTSD)
As such, FMLA can be used for rehab in such cases of SUDs overlapping with the above. That is, as long as addiction constitutes a serious health condition as defined by the FMLA, which prevents the individual from carrying out their work, and as long as the employer’s insurance covers rehab.
Find Out If Insurance Covers IOP in Parkersburg WV; Understanding Your Insurance Terms
With the above in mind, we should repeat that health insurance is indeed a very complex subject. You’ve already likely noticed terms that don’t see much use in everyday language, and plans tend to use quite a few. In this regard, to determine just what your plan covers, you should be able to understand your insurance terms.
For some initial help, here we can note the most vital ones among them.
- Preferred provider or in-network provider. Health insurance providers typically have contracts with healthcare providers and healthcare provider networks. Thus, plans will refer to healthcare providers within these networks using these terms.
- Non-preferred or non-network provider. In contrast, these terms refer to healthcare providers outside of a health insurance provider’s network. Some plans do cover non-network provider services, but their coverage tends to be lesser than in-network services.
- Enrollment fee. This term refers to an annual amount you must pay to maintain healthcare coverage.
- (Monthly) Premium. A premium refers to a monthly maintenance payment some plans require.
- (Annual) Deductible. A deductible is a fixed amount, typically to be reset every year, which you must pay before cost-share begins.
- (Post-deductible) Cost-share. This term refers to a percentage of the final cost of rehab services you must pay after deductibles. It differs from “copayment” in that cost-share is a percentage, whereas copayments are fixed amounts.
- Out-of-pocket payment. As the name implies, this term refers to costs you must pay out of pocket outside of plan coverage. Many plans tend to have a limit for such payments.
If you’re still unsure if your insurance covers IOP in Parkersburg WV and beyond, you may also consult the following resources on insurance terms:
- The U.S. Centers for Medicare & Medicaid Services (CMS) healthcare glossary
- CMS’s uniform glossary
- The American Speech-Language-Hearing Association (ASHA) glossary of health care business terms
In either case, as we’ll cover next, it’s always advisable to check directly with your insurance provider once you’ve received an SUD diagnosis.
Which Rehab Programs Does Insurance Cover?
Having defined what insurance tends to cover, here we can briefly outline rehab programs in order. As we do, we will explain whether insurance typically covers them.
#1 Medical Detox
Also referred to as MAT (medication-assisted treatment), medical detox is often the first step on the journey to recovery. It typically takes place in clinical settings, but can also occur in outpatient facilities. In either case, medical detox allows the body to detoxify and deal with withdrawal symptoms in a safe environment. As an essential medical service, most insurance plans will cover programs for medication assisted treatment West Virginia providers will refer you to.
#2 Inpatient Programs
After medical detox, the common next step for moderate to severe SUDs comes in inpatient programs. Such programs offer 24/7 supervision and support in a safe clinical environment, where the individual can begin to heal. They may receive pharmacotherapy as needed, and psychotherapy will take center stage. As an equally vital medical service, if your insurance covers IOP in Parkersburg WV it will certainly cover inpatient drug rehab in WV.
#3 Outpatient Programs
The next step to recovery, as well as a standalone one for milder SUDs, comes in outpatient programs. These come in two varieties; Outpatient Programs (OPs) and Intensive Outpatient Programs (IOPs). In both cases, such programs will mostly focus on behavioral therapy and group therapy, advancing the recovery process. While they rarely include clinical services, unless urgently needed, such programs do tend to be covered by health insurance. The typical intensive outpatient program West Virginia treatment providers suggest tends to be covered more thoroughly, due to its intensity compared to OPs.
#4 Sober Living Homes
Finally, as a standalone step to recovery or a continued part of aftercare, come sober living homes. Such homes allow newly-rehabilitated individuals to live among their peers and maintain abstinence. Indeed, the typical sober living WV program will have demonstrably beneficial effects on rehabilitation, abstinence, and even relapse prevention.
Still, that your insurance covers IOP in Parkersburg WV doesn’t mean it will cover sober living homes. On the contrary, most health insurance plans will not, for a rather technical reason. American Addiction Centers (AAC) explains this as follows:
“Through the Affordable Care Act (ACA), insurance providers must cover 10 essential benefits, which include treatment for substance use disorders. While sober living homes are designed to help people recover from addiction in a safe and supportive environment, they are not considered treatment facilities.”
Which Types Of Addiction Does Insurance Cover?
Programs aside, you may wonder which types of addiction health insurance can cover. Thankfully, this answer is fairly simple; while coverage does vary, many healthcare plans will cover all kinds of SUD treatment. Among others, this can include:
- Alcohol rehab, in cases of Alcohol Use Disorder (AUD)
- Cocaine rehab
- Stimulants rehab
- Heroin rehab
- Marijuana rehab
- Opiate rehab
- Meth rehab
- Fentanyl rehab
- Ambien rehab
- Barbiturates rehab
- Benzodiazepine rehab
If you don’t see a specific SUD on this list, it is still more than likely covered as long as it’s comparable to the others. Treatment for most SUDs tends to entail similar services and programs, thus falling under virtually the same umbrella.
Verifying That Your Insurance Covers IOP in Parkersburg WV and Beyond
That said, we must once again stress that healthcare coverage differs very significantly. As such, we must echo AAC’s advice that “it’s always best to check with your insurance directly to verify your plan’s specific coverage”. The information we’ve given here largely consists of points of reference and common occurrences, but each case differs,
As such, to ensure an uninterrupted journey to recovery, you should:
- Explore additional resources, such as our aforelinked pages and AAC’s relevant resources at your leisure.
- Contact your health insurance provider to review your plan’s exact coverage and applications.
- Consult your addiction treatment providers to explore coverage and additional financing options.
What If the Full Cost of Rehab Isn’t Covered By Your Insurance?
Still, there may be cases where your insurance covers IOP in Parkersburg WV, but your plan only covers a fraction of your total rehab costs. Severe SUDs may require lengthy treatment, for example, extending beyond your plan’s benefits. In other cases, your coverage may mostly suffice but still not cover the full cost of rehab.
In such cases, you will have to consult your addiction treatment provider and explore alternative financing options. These may vary from provider to provider, and may depend on remaining costs after coverage, but will typically include:
- Personal loans
Should you choose Harmony Ridge among our WV peers you can rest assured our representatives will thoroughly assist you in this regard. Our philosophy mandates that we offer our services as far as possible, as freedom from addiction is an invaluable gift. In line with this principle, we can’t let costs discourage anyone from seeking rehabilitation and reclaiming their life.
Can a Family Member Pay For Your Treatment?
Finally, both we and many of our peers also allow for payment arrangements within families. It’s very common to want to pay for the rehab of a loved one, before or after insurance coverage. Thus, it’s not an option many treatment providers neglect nowadays.
A typical concern in such cases comes from the side of paying family members. As much as they want to help, they also need the reassurance that their funds are being used as intended. So, arrangements for direct payments to treatment providers tend to work best in such cases.
Harmony Ridge Recovery Is Here For You
Whether your insurance covers IOP in Parkersburg WV fully or partially, we at Harmony Ridge will accept all major healthcare providers’ plans. Our representatives will thoroughly review your plans and explore financing options with you, setting your mind at ease in advance. We deeply understand how complicated health insurance coverage seems, and we always strive to demystify it as best we can.
If you have further questions, or are now ready to take the first step forward, please contact us today. Our teams will assist you discreetly and professionally, without any obligations on your part. They will contact your health insurance provider for you if you wish, always with strict confidentiality. And if you do choose us as your treatment providers, they will help set your course for an unforgettable journey to recovery.