Using Providence Health Plan for Drug Rehab

Providence serves individuals primarily in California, Oregon, Washington, Montana, and Alaska.
It is considered the third largest not-for-profit healthcare system in America, providing coverage for more than a half-million people nationwide on Providence health plans. With extensive coverage options, Providence is a part of a network of close to a million healthcare providers around the country that offers covered healthcare services for its members.

By providing its members with many plan options, Providence also offers a host of additional benefits to enhance a healthy lifestyle and promote good health. One such benefit is access to FitTogether, which offers a range of services and programs, including a monthly newsletter with tons of helpful information delivered via email, health and wellness classes, and  a 24/7 registered nurse hotline (ProvRN) for instant medical advice. Another helpful tool for members is myProvidence, an online secure member website where individuals can keep track of their health plans, medical information and records; review claims; and estimate treatment costs before obtaining services. Providence is a health services and health insurance provider that works with employers and individuals to provide quality healthcare and insurance coverage for members for a variety of health needs, including drug rehab.

Understanding Insurance Terms

Happy therapist talking with a rehab group at therapy sessionIn order to better understand how to use insurance to pay for things like drug rehab, it is first important to know the lingo and terms that are used. Here is a guide to common insurance terms that will likely come up and their definitions:

  • Deductible: This is the amount a person will need to pay before health insurance coverage kicks in and covers the rest. Usually, this is an annual amount, and once the deductible is reached, the insurance company typically pays for services at a preset rate or percentage.
  • Premium: This is what a person will pay each month to remain covered by an insurance plan. Premiums do not count toward a person’s deductible amount.
  • Copay: This is usually a small fixed amount, generally ranging from $10 to $50, that an individual pays at the time of service. Copayments do not count toward deductible amounts and may differ for the type of service or appointment needed.
  • Co-insurance: This is the amount paid by the insurance company, generally after the deductible is reached. For example, some plans may cover 80 percent of the cost of services after a deductible amount is met, requiring individuals to cover the remaining 20 percent, while others may pay 100 percent, leaving no remaining cost to covered individuals.
  • In-network: Insurance companies have agreements with particular providers to offer rates at a discount for members. In-network providers typically provide the lowest cost for services.
  • Out-of-pocket expenses: This is the amount individuals will pay themselves for care.
  • Out-of-pocket maximum: This is typically the maximum annual amount that individuals and families will have to pay. This means that once a person (or family) has reached this maximum, any other costs will be covered by the insurance company.

Providence Health Plan’s Covered Services for Substance Abuse

There are differences in the types of insurance plans offered and what they cover. A general overview follows:

  • Preferred Provider Organization (PPO): Individuals can go to any provider of their choosing without a referral. In-network providers will generally be the most affordable options.
  • Health Maintenance Organization (HMO): Individuals choose from providers who are in-network and a referral is required for specialized services. Out-of-network providers are not covered.
  • High Deductible Health Plan (HDHP): Individuals who wish to pay lower monthly premiums usually have to pay more out of pocket to reach a higher deductible amount before services are covered.
  • Health Savings Account (HSA): Often combined with an HDHP for eligibility, an HSA is a specialized tax-advantaged account that individuals can put money into to pay for medical expenses.
Providence’s health plans include Balance, Choice, Connect, Standard, and HSA Qualified in Gold, Silver, and Bronze levels, and the Providence Essential plan. Generally speaking, Gold-level plans will offer the highest level of coverage, usually with higher monthly premiums, lower deductibles, lower copays, and lower out-of-pocket maximum expenses, as compared to Silver and then Bronze plans. The Balance, Standard, and HSA Qualified plans allow individuals to seek treatment from any provider, whether they are in the Providence Signature Network or not, without requiring a referral for specialty services, while the Choice and Connect plans require individuals to stay within their home network and receive a referral for care from a specialist. The Essential plan is only for individuals under 30 who do not anticipate many medical expenses; therefore, coverage is offered with higher deductibles and lower monthly premiums. Individuals may seek care from any provider without a referral.

Substance abuse and mental health services are included as one of the 10 essential health benefits that are required to be covered equally to other medical services under the Affordable Care Act, according to

Mental health and substance abuse services are generally considered in the same category for Providence healthcare plans. Both residential and outpatient services are covered at variable rates after the deductible is met, depending on the plan.

The following example rates (2016 plans available in Oregon) indicate what each individual will be responsible for paying out of pocket for mental health and substance abuse services after their deductible has been met each year:

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Substance abuse services may include medical detox, stabilization services, inpatient/residential treatment options, and outpatient care programs. Providence may cover up to 30 days for inpatient rehab and 30 outpatient rehab visits per calendar year, covering care that is specifically deemed medically necessary.

Finding and Enrolling in a Covered Substance Abuse Program

In order to use a Providence health plan to pay for substance abuse services, individuals generally start with their primary care physician who can then provide a referral to specialty services like drug rehab. Individuals should check to ensure that the rehab center is an in-network provider, and if not, what the cost may be and at what rate the out-of-network care will be covered. The staff at a substance abuse facility can help families determine if their insurance covers rehab and calculate what the out-of-pocket expenses may be.
Providence also has a customer service center staffed from 8 a.m. to 5 p.m. to take calls about coverage and providers, as well as a provider search tool on the website. Individuals can search for care providers using this tool. People can also look at their plan information paperwork to determine what will be covered, at what rate, and if deductibles are required to be met first. It is important to read through all this information, or speak with an insurance provider professional, to better understand the extent of coverage and what is required for coverage before enrolling in a drug rehab program.
Consulting With Expert.In some cases, residential rehab may not be deemed medically necessary until an individual has first tried an outpatient program and then relapsed. Most insurance will require the “medically necessary” designation in order to cover treatment. An individual will need to be referred through their primary care physician first, although a referral may not be required for all plans. Specific states may have differing plans that have a range of covered services and rules surrounding how coverage works. It can be helpful to check with the behavioral health department of the state of residence for more information.

Just because residential treatment is not 100 percent covered in a particular plan does not mean that none of the services are covered either. Perhaps the plan will cover group therapy sessions and detox, for example. Some plans may cover therapy only while others may also cover alternative care such as chiropractic care, or music or art therapy as long as it is part of an approved treatment program.

There are many options for self-pay or financing drug rehab too. Professionals at a substance abuse treatment center can be some of the best resources for helping individuals and families navigate what insurance may cover and what may need to be paid or financed.

Drug abuse and addiction can cost individuals, families, and society in general a significant amount of money each year.

The National Institute on Drug Abuse (NIDA) estimates that addiction treatment programs can save everyone money in healthcare costs and criminal justice expenses at rates exceeding $12 for every $1 spent on treatment.

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