What Are HMO Plans?
An HMO (Health Maintenance Organization) is a type of health insurance plan where individuals must choose a primary care physician (PCP) and seek medical services within a network of approved providers. HMO health insurance plans typically offer integrated care focused on prevention and wellness. Specialists often require referrals and out-of-network care is generally not covered except in emergencies.1
HMO plans differ from PPO (Preferred Provider Organization) health insurance plans. PPO health insurance plans often offer increased flexibility, allowing individuals to visit any healthcare provider without needing referrals, but with varying levels of coverage.1
Do HMO Insurance Plans Cover Addiction Treatment?
Yes, HMO health insurance plans provide full or partial coverage for drug addiction or alcohol addiction treatment. The Affordable Care Act (ACA) passed in 2010 mandates all Marketplace plans to cover 10 essential health benefits, including mental health and substance use services. This means HMO health insurance plans are required to provide at least partial coverage for addiction treatment.2
The extent of drug and alcohol rehab coverage through an HMO can vary depending on several factors, such as your specific health insurance plan. Some HMO health insurance plans may offer comprehensive coverage for addiction rehab, including inpatient detoxification, residential treatment, outpatient treatment, and medication-assisted treatment. Other plans may only cover certain types of treatment or have limitations, such as the length of time covered at a rehab facility.2
Factors such as medical necessity, the type of treatment received (e.g., inpatient vs. outpatient), and whether the treatment facility is in-network or out-of-network can also impact coverage. By reviewing your HMO health insurance plan, contacting your insurance provider, or consulting with a healthcare professional, you can better understand the specifics of your coverage for addiction rehab services.2
Do HMO Plans Cover Mental Health Services?
Yes, HMO health insurance plans may offer full or partial coverage for mental health services. The Affordable Care Act (ACA) mandates all Marketplace plans to cover mental health services. This means that individuals with HMO health insurance plans should have access to mental health treatment.2
It is common for individuals with a substance use disorder (SUD) to also have a co-occurring mental health disorder, such as anxiety, depression, or post-traumatic stress disorder (PTSD). Treating both disorders at the same time is sometimes referred to as dual diagnosis treatment or integrated treatment and can lead to better patient outcomes.3 Because mental health and substance use services are covered under the ACA, your HMO health insurance will provide coverage, to an extent, if you have more than one disorder.2
As mentioned, factors such as medical necessity, the type of treatment received (e.g., inpatient vs. outpatient), and whether the treatment facility is in-network or out-of-network can impact what is and is not covered, which is why it is important to familiarize yourself with your HMO health insurance plan.
What Types of Addiction Treatment Are Covered by HMO Plans?
HMO health insurance plans may cover various levels of substance use treatment. As mentioned, your HMO rehab coverage will vary based on several factors, so it is a good idea to contact your insurance provider ahead of time, so you know exactly what is and is not covered.
The following are common types of addiction treatment:4
- Detox is a process in recovery designed to help patients withdraw from certain substances while in a medically supervised setting. This can help ensure their comfort and safety. It can also ease the transition into a formal treatment program, such as inpatient or outpatient rehab.
- Inpatient care may be recommended for patients who need around-the-clock care and support or a more structured environment. With this type of care, patients live at the facility for the duration of treatment.
- Outpatient rehab provides similar treatment services as inpatient rehab, but patients live at home or in a type of recovery housing while receiving care. Outpatient rehab varies in duration and intensity. Standard programs may require weekly attendance, while an intensive outpatient program (IOP) or partial hospitalization program (PHP) may require daily attendance.
- Aftercare is recommended after patients complete a formal treatment program and is designed to support long-term recovery. Aftercare can include attending group meetings or living in a sober living home.
Types of Behavioral Therapy That May Be Covered by HMO Plans
Behavioral therapies are commonly used in the treatment of mental health disorders and substance use disorders (SUD) and work to modify maladaptive behaviors, emotions, and thoughts. Types of therapies used that may be covered by an HMO plan include:5, 6, 7
- Cognitive-behavioral therapy (CBT) helps individuals identify and change negative thought patterns and behaviors, fostering healthier coping mechanisms.
- Eye movement desensitization and reprocessing (EMDR) is primarily used for trauma-related disorders and involves bilateral stimulation to alleviate symptoms associated with distressing memories.
- Dialectical behavior therapy (DBT) helps address emotional dysregulation and combines elements of cognitive-behavioral techniques and mindfulness practices.
- Contingency management uses positive reinforcement to promote desired behaviors, such as abstaining from substance use.
HMO Insurance and Out-of-Network Addiction Rehabs
If your HMO plan does not have a partnership with a rehab or addiction treatment center, it means that seeking treatment at those facilities would be considered out-of-network. Out-of-network means that the treatment center does not have a contractual agreement with your insurance plan, potentially leading to higher out-of-pocket costs for you. In these cases, it is advisable to call your insurance provider to seek advice and explore available options. They can guide you in finding in-network providers or discuss any potential coverage exceptions or alternatives that may help minimize the financial burden of seeking addiction treatment.
- HealthCare.gov. (n.d.). Health insurance plan & network types: HMOs, PPOs, and more.
- HealthCare.gov. (n.d.). Mental health & substance abuse coverage.
- National Institute of Mental Health. (2023, March). Substance Use and Co-Occurring Mental Disorders.
- Substance Abuse and Mental Health Services Administration. (2014). What is substance abuse treatment?
- National Institute on Drug Abuse. (2019). Treatment approaches for drug addiction drugfacts.
- National Alliance on Mental Illness. (n.d.). Psychotherapy.
- May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder.