How to Pay for Addiction Treatment With OptumHealth
Have you heard of OptumHealth? If you have a Medicare Advantage plan, then you may have seen the name OptumCare or OptumRx while trying to navigate the rehab insurance process for addiction treatment.
OptumCare is the name for the OptumHealth network of patients and providers. OptumCare does not provide insurance plans or policies, but they work with your insurer as a low-cost local medical group.
OptumCare usually operates as a series of clinics within a medical group rather than a hospital, facility, or treatment center.
You won’t be able to go to an OptumCare rehab because there aren’t any, but that’s not a problem—you can use OptumCare providers to start the treatment process and use the referrals to get substance abuse treatment coverage with another facility for the actual residential stay.
If Optum is part of your insurance network, they won’t be the administrator of the actual plan—you’ll most likely have Optum’s parent company, UnitedHealthcare, for your actual plan. However, your network will include the UHC network and the network of Optum local medical groups.
A major benefit of choosing care with OptumHealth is that the cost savings can be substantial, even if you’re used to Medicare prices. Optum’s mission statement is providing affordable care, making it a low-cost treatment choice for many people.
When you use OptumHealth providers to get your addiction care, you’ll apply your primary insurance coverage, since OptumHealth isn’t a rehab health insurance plan, it’s a network of providers.
The insurance that your local Optum medical group accepts can vary based on your geographical location. However, if you have Medicare or Medicaid, Optum probably accepts your insurance. The same is true if you have a non-state-sponsored plan through UnitedHealthcare or another partner insurer.
It’s important to have a plan to pay for treatment before your recovery begins. You don’t want to find yourself dealing with bills or on hold with insurance when you’re supposed to be focusing on your recovery!
Here’s what you need to know about paying for addiction treatment with Optum Health:
Will My OptumHealth Addiction Treatment Be Covered By My Insurance Plan?
OptumCare addiction treatment is covered by many insurance plans, but you’ll have to check with yours to be sure.
Most insurance plans cover OptumCare treatment as long as:
- OptumCare accepts your insurance, and
- OptumCare is in your insurer’s network (unless you have a HMO plan that allows you to go out-of-network)
Providers in OptumCare medical groups accept a wide variety of insurance plans, including Medicare Advantage plans. The insurances accepted usually vary from area to area, so check with your local OptumCare group to find out if they accept your insurance.
All insurance plans are required to cover medically-necessary treatment for pre-existing conditions such as substance use disorders. The only exceptions are:
- Grandfathered insurance plans that haven’t changed substantially since the Affordable Care Act in 2010
- Short-term insurance plans, which include emergency plans, gap plans, and travel plans and only cover unforeseen medical events
It’s very likely that your addiction treatment will be covered as long as your plan isn’t an exception.
To be sure, call your insurance company at the phone number on your member ID card. The agents on the line can confirm your coverage for addiction treatment and check whether OptumCare providers near you are in-network.
How to Check Optum Health Addiction Coverage
You should always check your insurance coverage early in the process when seeking addiction treatment. Even if you’re going to an out-of-network treatment center, OptumCare will still be involved in the entire process with your insurance.
That’s because of the way the insurance process works for covering addiction treatment. The process starts with your OptumCare family doctor, since you must get a referral and a pre-authorization before your insurer can decide to cover your treatment.
That means you need to confirm insurance coverage for your OptumCare primary care visit. You may need coverage for a behavioral health specialist appointment for the pre-authorization as well.
Here’s how to check your insurance coverage for OptumCare:
Check Your Insurer’s Website
Most insurance companies have a members-only portal where you can log in and check specifics about your coverage.
You can usually find the portal on your insurer’s website navigation. It may be listed on your member ID card or the documentation you receive in the mail when your insurance plan renews each year.
You should be able to use this portal to locate in-network providers, including OptumCare providers that work with your insurance company.
Call Your Insurance Company
The best way to find your coverage quickly is simply to call the number on your member ID card. That number connects you with the customer service agents who can locate your coverage and tell you which nearby OptumCare providers you can use.
Call Your OptumCare Medical Group
If you already have a relationship with an OptumCare clinic or provider, you can check your coverage by giving their office a call.
If you don’t have a relationship with OptumCare yet, give them a call anyway! If you let them know that you’re hoping to see a primary care doctor or specialist within the medical group, they’ll be happy to help you.
Most offices are happy to check insurance coverage for you, and they already have the information on file from previous visits.
Call Your Medicare Office
If you have Medicare Advantage and see OptumCare providers as a condition of your coverage, call your Medicare office to learn the specifics about your coverage.
They can walk you through what’s covered and what’s not, as well as what processes you need to follow to get addiction treatment covered.
Call Your OptumCare Primary Care Doctor
You may already have an OptumCare doctor, or maybe you’re new to Optum but have a doctor’s office in mind within their local medical group.
Either way, you can call your OptumCare primary care office to ask for help verifying your insurance coverage. They’ll be able to let you know what’s covered, how much, and which OptumCare specialists you can go to for the pre-authorization.
How Does Coverage for OptumHealth Addiction Treatment Work?
The exact process for getting addiction treatment covered when OptumCare is your provider depends on your insurance company, plan, and policy. However, the insurance coverage process tends to be very similar no matter who your insurer is.
Step 1: Confirm Your Coverage
The first step is to make sure that your insurer covers:
- Your OptumCare providers, including the family care and specialist appointments you may need before entering treatment; as well as any outpatient care you receive from OptumCare behavioral health doctors.
- Other providers that work with OptumCare to meet the full spectrum of your medically-necessary care. That can include outpatient clinics, out-of-network specialists, or inpatient rehab facilities.
You can double-check this coverage by:
- Calling your insurance company directly
- Calling your state Medicare or Medicaid office if you have a Medicare Advantage plan that works with an OptumCare medical group
- Calling your OptumCare medical group
- Calling your primary care provider
- Checking the online member portal
Note that this is the process for confirming OptumCare coverage only. If you’re seeing OptumCare for referrals and pre-authorization but your treatment center is outside of the medical group, you’ll need to confirm rehab coverage separately.
You can do that by calling your insurer or the rehab facility you’ll be attending, or by logging in to the online portal.
Step 2: Let Your Insurer Know
Once you know that your treatment is covered, it’s time to tell your insurance company that you’ll be using your coverage.
This part is simple; all you need to do is give your insurance company a call and let them know you’re getting treatment through the OptumCare medical group.
If part of your drug rehab treatment will be at an out-of-group facility, e.g. inpatient residential treatment, then let them know about that now, too. You can take care of that in the same phone call.
Step 3: See Your Family Doctor
Your insurance company will want you to see your OptumCare primary care doctor before you start treatment. That’s because the insurance process for getting OptumCare treatment covered requires a referral, which your doctor can provide.
Most insurance policies require that you prove medical necessity before they’ll cover treatment for a pre-existing condition like substance use disorders. Referrals are one way your family doctor can certify that you need treatment by referring your care to an OptumCare specialist or a treatment facility.
Step 4: Get Your Prior Authorization
Prior authorization is another way for your care team to prove to your insurer that you need treatment. It’s a common part of the insurance process for
You may need a prior authorization from a specialist, or you may be able to get it from your primary care team. Your insurance company can let you know, but it’s more likely that your OptumCare medical group will handle the pre-authorization for you.
Step 5: Determine Your Financial Responsibility
Once the insurer determines how much treatment to cover, you can start making a plan to cover the difference.
Your insurance company will make a decision on coverage for your addiction treatment once they receive all of the documentation. That includes:
- Your medical record from your primary care team at OptumCare
- Your referral, also from primary care
- Your prior authorization, which may come from primary care or a behavioral health specialist
The insurance company may approve partial or full coverage for addiction treatment depending on factors like whether the OptumCare provider was in-network.
If you receive partial coverage, the insurer will let you know the portion of treatment costs that you’re responsible for covering. Your provider usually lets you know before you can receive a letter in the mail from insurance.
You’ll get an Explanation of Benefits, a form that explains how your coverage was applied and what the remaining balance is. If you have any questions about the Explanation of Benefits, you can call your insurance company and they’ll give you more detail.
Once you know what your financial responsibility is, you can start making a plan to cover it. You should do this before you enter treatment, so you’re not worrying about it when you should be recovering!
Do Insurance Plans Cover OptumHealth Addiction Treatment?
Your insurance plan is required to cover addiction treatment that is:
- Medically necessary
- With a provider that your insurer covers
That means insurance will cover your care with an OptumCare provider, but you need to make sure that the provider accepts your insurance.
There are only a few exceptions:
- Your OptumHealth provider doesn’t accept your insurance
- Your insurance plan existed before 2010 and hasn’t changed since then
- Your insurance plan is a temporary, emergency, or travel plan
The types of medically-necessary addiction treatment that your insurance plan covers with OptumCare providers includes most specialist care. That may include any of the following:
- Appointments to receive medication
- Assessments, testing, and diagnosis
- Follow-up appointments
- Outpatient programs
- Medication-assisted treatment programs
- Medications for opioid and alcohol use disorders, which you can get from OptumRx, another low-cost Optum healthcare service
What Types of Addictive Substances Are Covered by Insurance?
If you’re looking for an insurance policy to cover your OptumCare and out-of-group addiction treatment, you may be concerned that the type of substance you used will affect how your insurance company covers treatment.
The good news is, the type of substance doesn’t matter as much as the kind of treatment.
Your insurance company will cover your OptumCare group treatment for any substance that causes physical dependence. That’s as long as your OptumCare group works with your insurer.
Instead of seeing that you used a particular drug, your insurer wants to know that you meet the criteria for substance use disorder or one of its related disorders. If you aren’t able to control your substance use, it’s likely that your OptumCare treatment will be covered.
That being said, insurance companies cover different treatment types for each kind of substance. Your insurance company only covers evidence-based treatment, which means that research supports its use in a certain substance recovery.
Insurance Coverage for Alcohol Addiction Treatment
Your insurance company will cover alcohol addiction treatment with OptumCare or another provider as long as you have an alcohol-related substance use disorder, including:
- Alcohol abuse disorder
- Alcohol withdrawal syndrome
- Binge drinking disorder
For alcohol use disorders, most detox insurance covers treatments like:
- Detox treatment, including monitoring, 24/7 care, symptom management, and intravenous fluids
- Medication-assisted treatment, including the use of medications like disulfiram, naltrexone, or acamprosate to control alcohol withdrawal, cravings, and relapse
- Residential inpatient treatment with services that may include therapy, counseling, medication, group treatment, holistic recreation, and more
That’s not a full list of all that your insurer may cover, so call your insurance agent at the phone number on your ID card to verify.
Insurance Coverage for Prescription Drug Addiction Treatment
Your insurance company covers prescription drug addiction treatment, but only for certain dependence-causing drugs. The most common ones and their generics include:
- Opioids used to treat pain, including Norco (hydrocodone), OxyContin (oxycodone hydrochloride), Percocet (oxycodone with acetaminophen), and Palladone (hydromorphone)
- Stimulants used to treat ADHD, including Adderall (amphetamine salts), Ritalin (methylphenidate), Dexedrine (dextroamphetamine) and Vyvanse (lisdexamfetamine)
This isn’t a comprehensive list, so check with your insurer if you don’t see the right drug type listed.
Insurance covers treatment whether it’s from OptumCare or not, but the services that are covered can be a little different.
Insurance Coverage for Prescription Opioids
When you get treatment for prescription opioid addiction, your insurer will most likely cover services such as:
- Medical detox, including supervision and care to keep you comfortable and safe
- Residential treatment, which may last 60 days or longer and includes both behavioral and medication-assisted treatment
- Medication-assisted treatment to manage withdrawal and cravings, which may include buprenorphine, methadone, or naltrexone
Insurance Coverage for Prescription Stimulants
Most insurance covers a combination of medical detox and residential treatment for prescription stimulant abuse. Your insurance may cover a longer detox than typical, since stimulants have a long withdrawal period.
Medication-assisted treatment is generally not covered for prescription stimulants because it’s not evidence-based. There’s no research supporting the use of medications to reduce stimulant withdrawal, cravings, or relapse risk.
Insurance Coverage for Heroin Addiction Treatment
All insurance companies cover heroin addiction treatment that’s medically necessary and evidence-based.
That includes medical detox with 24/7 symptom management and care, residential treatment that includes behavioral and medication-based interventions, and medication-assisted treatment to manage long-term recovery.
The medications covered in heroin treatment include buprenorphine, methadone, and naltrexone.
Insurance Coverage for Cocaine Addiction Treatment
If you have a cocaine addiction, then your insurance company will most likely cover it as treatment for substance use disorder involving stimulants.
In that case, your covered treatment will include:
- Medical detox: The detox services that are covered often include constant care and monitoring, as well as care to keep you comfortable.
- Residential treatment: Insurance usually covers residential treatment and the services it includes, like therapy. Cocaine has a long post-acute withdrawal even if you complete detox, so your covered residential stay may be longer than usual.
Your insurance company probably will not cover medication-assisted treatment for cocaine addiction. That’s because medication is not an evidence-based treatment for stimulant use disorder.
Insurance Coverage for Meth Addiction Treatment
Most insurers will cover treatment for methamphetamine abuse as long as you meet their requirements for coverage.
Your covered meth treatment could include detox and residential treatment, including therapy and other behavioral interventions.
Insurance companies don’t cover medication-assisted treatment for meth because the research doesn’t say that it’s effective.
Do OptumHealth and Other Treatment Providers Need to Be In-Network?
Your treatment provider may need to be in-network for your insurance plan to cover it, but that depends on the kind of plan you have.
There are two common types of health insurance plans: Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs).
In-Network vs. Out-of-Network Providers with HMOs
If you have an HMO plan, all of your addiction treatment providers must be in-network to receive coverage.
That includes the primary and specialty care you get during the referral and prior authorization process, as well as the treatment center you choose.
If you choose a provider that isn’t in network, including OptumCare providers, you won’t receive any coverage at all.
In-Network vs. Out-of-Network Providers with PPOs
When you have a PPO plan, you can choose addiction care providers that are in- or out-of-network. This allows you extra flexibility when choosing where to go. With a PPO plan, you’ll pay extra for out-of-network providers, but they’re still covered in part.
How Can I Pay the Costs Not Covered by My Health Plan?
When it’s time to figure out your financial responsibility for the care you’ll receive from OptumCare specialists and out-of-group treatment centers, you may find that your insurance plan only covers treatment in part.
That means you’ll need to figure out how to cover the difference, so it’s important to have a plan for funding addiction treatment before you get to that point.
- Rehab scholarships: Private organizations like 10,000 Beds take applications from people who need treatment and arrange fully-paid treatment stays. The competition is fierce, so apply early.
- State-funded programs: If your primary insurance is self-paid or through your employer, then you may be able to cover the gap with Medicare or Medicaid (if you qualify).
- Your local community: Your local churches, 12 Steps, YMCA, and other resources may know where to send you for Good Samaritan help in the area.
- Treatment discounts: Some treatment centers offer a lower price for patients who pay out-of-pocket (either partially or fully).
- Insurance appeals: If you think your policy should cover more of your medically-necessary treatment, talk to your OptumCare provider or rehab to appeal the insurance decision.
OptumHealth Addiction Resources
OptumHealth offers the following resources to OptumCare members:
Why Choose Bedrock Recovery Center?
Once your insurance coverage is set in stone, it’s time to find the right treatment provider for you. OptumCare offers great, affordable primary care and specialist care—but most people need residential rehab to cement their recovery.
After your OptumCare provider handles your referral and prior authorization, Bedrock Recovery Center can manage your recovery in tranquil Canton, MA. Just a short trip from Boston, Bedrock offers the best evidence-based care from compassionate addiction clinicians.
Call us today to learn how we can help!