PPO Vs. HMO Insurance For Addiction Treatment

According to a survey by Bend Financial, 56% of Americans admitted to feeling “completely lost when it comes to understanding health insurance.” And this includes confusion about the different types of health insurance that are available. 

For instance, PPO Vs. HMO addiction treatment: Which is better, and can you actually get the care you need with the insurance you have?

Of course, it depends. Insurance policies and coverage can vary a great deal, even among plans in the same overall classification of coverage. PPOs and HMOs are one such example, as these similar types of plans have important differences between them that you should understand ahead of time, especially if there is the possibility that you will need PPO vs. HMO addiction coverage in the future. 

PPOs Vs. HMOs In A Nutshell

HMOs tend to be cheaper but limit you to a specific network of providers. You will generally need a referral from your healthcare provider to see specialists, including addiction treatment providers. 

PPOs are more expensive but offer more flexibility for treatment wherever you need it, whether in or out of your network. You can often see specialists, including addiction treatment providers, without a referral. 

Of course, health insurance plans can vary a great deal even if they are the same overall type of plan. Contact your health insurance provider directly or reach out to Ark Behavioral Health to learn more about your plan, your coverage, and to receive a cost estimate for your own treatment program. 

A More In-Depth Look At PPOs

PPO stands for preferred provider organization. This is a network of doctors, hospitals, and other healthcare providers that have agreed to provide care at a reduced rate as part of a healthcare system. However, PPO plans do allow you to receive covered healthcare services at providers who are not a part of this network, though these services may come with a higher copay or other higher out-of-pocket costs. 

While PPOs do tend to have a higher monthly premium than HMOs, many people prefer them due to the greater degree of flexibility that they offer. PPOs usually allow you to self-refer to specialists without having a referral from your regular family practice doctor, and you may not even need to maintain a primary care doctor at all, allowing you to see a different doctor of your choosing whenever you need to. 

Unsurprisingly, PPO plans are also highly recommended for people who travel often, as they can allow you to receive care when you need it, wherever you happen to be, not just in your local area. PPO plans are also widely available at almost every level of coverage through almost any health insurance provider in every U.S. state and, according to a study by KFF (formerly The Kaiser Family Foundation), PPOs represent the most common type of health insurance plan, with 49% of all U.S. covered workers enrolled, compared to 12% for HMOs. 

A More In-Depth Look At HMOs

HMO stands for health maintenance organization. As with a PPO, this is a network of doctors, hospitals, labs, and other healthcare providers that have agreed to provide members with healthcare services at a reduced rate. However, unlike PPOs these plans usually limit you to their own network providers more strictly, with exceptions for emergency care, and put more focus on preventative treatment services. 

HMOs also generally require you to have a primary care physician and to work with them and get referrals to specialists before you see them. You will also be far more limited in your options for specialists, including addiction treatment providers. 

The trade off, of course, is that HMOs generally offer cheaper monthly premiums than PPOs with comparable deductibles and out-of-pocket maximums, and may offer cheaper prescription pricing as well. This can make an HMO a good fit for a person who stays in a certain area and doesn’t often travel. 

As with PPOs, HMO plans are commonly available across many different levels of coverage through almost any health insurance provider in every U.S. state. 

Do PPOs Cover Addiction Treatment Services?

The Affordable Care Act of 2010, also known as the ACA or Obamacare, had a dramatic impact on how health insurance providers dealt with mental health treatment and behavioral health treatment, including substance abuse treatment. Under the ACA all long-term group and individual health insurance plans must cover mental healthcare and behavioral healthcare services as essential health benefits, including addiction treatment services. 

This means that PPOs must provide coverage for addiction treatment services. And, because of the greater flexibility that PPOs are known for, you generally have more freedom to pick the specific addiction treatment provider that you would like to work with, though staying in-network may help you save costs. 

With a PPO plan, you will also usually have more freedom to self-refer to addiction treatment services, without necessarily going through your primary care physician for a referral. 

Do HMOs Cover Addiction Treatment Services?

HMOs are subject to the same federal laws and regulations as PPOs and other long-term health insurance coverage. This means that, under ADA rules and regulations, HMOs must also cover addiction treatment services as an essential health benefit. However, HMOs do offer less flexibility in this coverage than PPO plans. 

Whereas PPO plans give you the freedom to pick between in-network and out-of-network treatment providers, receiving coverage at either a preferred or out-of-network rate, HMO plans will often limit you to providers who are a part of your specific provider network. 

In addition, HMO treatment policies generally require you to go through your primary care physician to access this care. This means you have to contact your doctor, potentially make an appointment, and receive a formal referral for addiction treatment services. 

Even with these limitations, however, HMO plans can help make the cost of your treatment much more affordable than paying out of pocket, depending on your specific situation. 

Types Of Addiction Treatment Covered

You can use your health insurance coverage to pay for a wide range of accepted, evidence-based addiction treatment services in inpatient, residential, or outpatient treatment settings. These services generally include:

• medical detox: close support and medical supervision provided to help clients manage acute withdrawal symptoms after they first discontinue drugs or alcohol
• behavioral therapies: talk therapies like cognitive behavioral therapy (CBT), which can help clients to identify and change harmful thoughts, feelings, and behaviors that have contributed to their substance use
• psychoeducation: educational sessions designed to teach clients about addiction, recovery, relapse, and other important subjects, giving them the knowledge to make positive and intentional choices in the future
• medication-assisted treatment (MAT): a proven treatment method that uses FDA-approved prescriptions like naltrexone, methadone, and buprenorphine to enhance the treatment of opioid use disorders or alcohol use disorders
• dual diagnosis treatment: an intensive, highly personalized treatment service provided by specialized rehab centers to treat SUD alongside co-occurring mental health disorders like anxiety disorders, depression, ADHD, OCD, and others
• peer support groups: which help groups of people facing addiction come together, build relationships, practice social skills, and share their thoughts, feelings, concerns, and achievements in recovery
• aftercare coordination: which organizes long-term resources for clients to use to continue their recovery in their local area, often including self-help groups, step-down care, employment assistance, and case management

Remember, addiction recovery is a lifelong process and you may need to participate in several different addiction treatment services in succession depending on your unique needs and the progress or setbacks you experience. 

Ark Behavioral Health 

Do you or someone you love need care for a substance use disorder? We can help. Ark Behavioral Health offers leading residential treatment services for all forms of drug use disorder and alcohol use disorder, as well as dual diagnosis care and residential mental healthcare for a wide variety of mental health conditions. 

To learn more about our personalized recovery services in Massachusetts and Ohio, please contact Ark Behavioral Health today.