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UnitedHealth Insurance Coverage for Heroin

What Kind of Coverage Does UnitedHealth Insurance Offer for Heroin Addictions?

doctor reviewing UnitedHealth group insurance forms on a clipboardUnited Behavioral Health (now known as Optum Provider Express or Optum Behavioral Solutions) is the organization which handles most of the substance abuse and chemical dependency coverage for UnitedHealth Group. For the purposes of this article, United Behavioral Health (UBH) and Optum are interchangeable. United Behavioral Health / Optum is a ‘personal health improvement service’ with an excellent reputation for behavioral disorder insurance coverage. For those battling heroin addiction, UBH coverage, including:

Optum has set up a member website, which has information on coverage and even provides a search tool to help locate a treatment facility. Unlike some other insurance plans, UBH/Optum does not require pre-authorization for certain outpatient services. UBH partners with both Medicaid and Medicare. It is important to note that not all programs are covered, even if a treatment is described on a UnitedHealth website. Refer to your Summary Plan Description for a list of all covered benefits under your health plan.

How Much of the Cost of Rehab is Covered by UnitedHealth Insurance?

Select diagnostic and detoxification services may be covered completely through United Health Insurance plans. It is also possible that withdrawal management medications are completely covered. For some in network providers, UnitedHealth Group Insurance requires a zero percent copay but do require you to meet an annual deductible. Out of network inpatient or outpatient services generally range around 20 percent for a copay as well as an annual deductible amount. Heroin addiction is a serious disease and it is strongly recommended that you speak with a UnitedHealth Group or Optum representative to discuss the best / most cost-effective rehabilitation services.

Can I Pay Above What My Insurance Will Provide to Receive Treatment?

Yes. However, some plans do have ‘Out-of-Pocket Maximum’ limitations. There are limitations on UnitedHealth Insurance coverage amounts for heroin addiction treatment, and some treatments or treatment centers may not be covered at all. You should request a copy of your policy for more information. Today, there are greater treatment options available to those suffering from heroin addiction than there were in the past. In general, insurance companies must offer the same services for chemical dependencies and substance abuse that they offer for medical or surgical conditions (per the Mental Health Parity and Addiction Equity Act of 2008). This helps ensure coverage, but also means that you may have to become pre-certified to receive treatment.

Inpatient Addiction Treatment vs. Outpatient Therapy

“United Behavioral Health / Optum is a ‘personal health improvement service’ with an excellent reputation for behavioral disorder insurance coverage.”

Heroin addiction treatment and rehabilitation programs can be classified into two broad categories: inpatient and outpatient. The severe nature of heroin symptoms might mean that partial hospital/day treatment programs are necessary (which are substantively different that most inpatient or outpatient options). The primary differences between outpatient and inpatient therapy revolve around residency; inpatient treatment programs require that the patient lives on site for the duration of treatment. Most outpatient programs are less expensive than inpatient programs, but offer fewer services and do not have 24-hour supervision. Optum preferred provider guidelines stipulate that heroin addicts should be admitted to outpatient services under the following circumstances:

  • individual is not an imminent risk for harm to self or others;
  • individual exhibits adequate behavioral control to be treated in outpatient setting;
  • co-occurring substance abuse is unlikely to undermine treatment;
  • there is no risk of withdrawal, or withdrawals can be safely managed.

If treatment is deemed to require observation and interaction for a minimum of 6 hours per week, Optum recommends intensive outpatient services or inpatient programs.

Should I Choose a Residential Rehab Center?

Residential rehab centers are treatment facilities that combine detoxification services, psychological counseling and after-care services. Keep in mind that UBH/Optum will review, recommend and authorize all inpatient services. The admission criteria for residential rehab programs for most Optum providers includes:

  • no risk of withdrawal, or withdrawal can be safely managed;
  • physical complications, if present, can be safely managed;
  • there is imminent or current risk of relapse which cannot be safely, efficiently and effectively managed in a less intensive level of care;

If you or your loved one is experiencing acute impairment of behavior or cognition that interferes with daily life, or if there are psychological or environmental problems which present threats to safety, then you should consider a residential rehab center. Before you are admitted into any residential center, consider the costs of the program and your coverage options. Also keep in mind that treatment methodologies vary between different centers, and not all centers are equally effective at providing treatment. Lastly, weight the impact on your own professional career or family life.

Will UnitedHealth Insurance Pay for Local Rehab and Out-of-State Treatment?

UnitedHealth Group is a nationwide provider of employer health and behavioral health insurance and has a network of treatment centers across the country. It is very likely that you will be able to find a treatment center nearby most major American cities. The Optum portion of UnitedHealth Group Insurance is actually three separate companies: Optum Health, Optum Insight and Optum RX. The coverage options available to you for local rehabilitation services or for out-of-state treatment can vary based on your plan. Visit to find a clinician or certify visits.

Does UnitedHealth Insurance Pay for Private or Luxury Treatment?

Private and luxury treatment rehabilitation centers may be covered through your UnitedHealth health plan. If your preferred treatment center is not already contracted with UnitedHealth or Optum, they can fill out a Facility Network Request Form to provide select levels of covered care. High-end treatment services come in both inpatient and outpatient clinics, but you should be aware that private, luxury and executive treatment options are very expensive. Some luxury treatment programs can cost in excess of $25,000 per month.

What Does Executive Treatment Offer Over Other Rehabs?

Unlike more traditional treatment facilities, executive and luxury rehab centers are designed to have a resort-style feel. Luxury amenities include private rooms, gourmet meals, swimming pools and spas, conference rooms, horseback riding and other accommodations. These are good options for members with excellent coverage or those with the financial resources to afford executive-level services on their own. For those who need to conduct business while going through an heroin rehabilitation program, these centers offer the ability to meet with business associates and maintain a comfortable working lifestyle while receiving help.

What Treatment Lengths Will UnitedHealth Insurance Pay For?

UnitedHealth Group insurance policy for Heroin addiction treatmentOptum does not always offer a clear explanation of what — and for how long — treatments are covered. Most UnitedHealth rehab centers or programs are outpatient, and some have treatment options that can run in excess of a full year. Inpatient programs typically last between 30-90 days. Your plan may have limitations on the number of days in which you can receive either inpatient or outpatient behavioral health services. Important: Many facilities will offer different treatment lengths, but not all facilities are covered through your health plan. If you have questions, contact a UnitedHealth Group or Optum plan representative.

What if I Have No Insurance?

If you or your loved one is suffering from heroin addiction but does not have insurance, you still have some options available to you. Most treatment centers understand that rehab programs are expensive and offer flexible payment plans. Some treatment centers are even free. The Affordable Care Act (more commonly known as “ObamaCare”) includes a program known as Screening Brief Intervention and Referral to Treatment, which is designed to stop substance abuse. SBIRT services may be useful for those with drug and heroin dependence. You can also speak with our specialists to identify your coverage options and potential treatment programs.

Using Our Helpline to Determine Your UnitedHealth Group Insurance Rehab Options

Sometimes the best way to determine the appropriate rehabilitation program is to speak with a professional, third-party advisor. We can help you or your loved one identify what your options are and help you understand the right choice given your specific situation. If you are looking to make the transition to a healthy lifestyle, call .

Question and Answers

Will UnitedHealth Insurance Cover Multiple Rehab Stays?

Maybe. UnitedHealth Insurance (or Optum Behavioral Solutions) may cover an additional visit. Your plan is more likely to evaluate and limit the total number of days, not the total number of stays, in rehab. Coverage will depend on the policy and individual member’s past use of benefits.

Does Insurance Pay for Aftercare?

Yes. UnitedHealth Group Insurance does offer select coverage for aftercare programs. Member benefits are subject to change based on network options, individual coverage and treatment methodologies.

Could Rehab Make My Insurance Premiums Higher?

Maybe. This is a significant fear among members of all health insurance plans, not just UnitedHealth plans. After a certain number of treatment days, member co-pays are likely to increase. Whether or not premiums rise depends on your coverage and type of plan and treatment type.

Has the Affordable Care Act (ObamaCare) Affected Substance Abuse and Mental Health Insurance Coverage?

Yes. The Affordable Care Act lists addiction treatment one of its ‘ten essential health benefits’ required of insurance exchange companies. The ACA has also made it illegal for companies to deny coverage to those with preexisting conditions, such as addiction and mental illness.

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