Getting the Care You Need With Optum Insurance

Living with a substance use disorder can destroy your health and make it hard to maintain relationships. That is why it is so important to seek treatment if you find yourself unable to stop using a drug despite the negative effects it has on your life.

However, for the average person, getting addiction care is not quite as simple as dropping everything and going to a rehab clinic. It is very common for people to worry about how they will pay for rehab, but you should not let that keep you from getting the care you need.

If you have healthcare through Optum, you probably have quite a few questions about how the company’s addiction treatment services work. Can you pick any rehab you want? Are there any hidden fees associated with treatment? Does Optum even cover addiction treatment?

The good news is that you can definitely get addiction care through Optum. Thanks to the healthcare changes from the Affordable Care Act, all insurance providers are required to provide addiction treatment. Substance use disorders are just like other mental health conditions or physical illnesses, so they deserve proper treatment.

An Overview of Optum Insurance Types

Optum is a little different from other insurance plans where you pay a fee and then get coverage at a variety of healthcare facilities. Instead, Optum is essentially a healthcare provider in its own right. People who have an insurance plan accepted by Optum can use their plans at one of the many Optum facilities around the country. Some of the many insurance providers partnered with Optum include UnitedHealthcare, Anthem Blue Cross, Blue Shield, Cigna, and Medicare.

To get addiction care through Optum, the first thing you need to do is figure out which type of insurance you have. Identifying your coverage category will help you learn what options are available to you.

Optum HMOs

The majority of insurance plans that go through Optum are HMOs. HMO stands for Health Maintenance Organization, and it is a type of insurance that strictly works in a network. You get a primary care physician from your Optum insurance network, and then the physician can refer you to specialists within the network as needed. This means that you will typically go see your doctor if you think you have an addiction, and then the doctor will recommend an Optum rehab facility where you can get treatment.

Optum PPOs and POSs

The other types of plans that give you addiction care through Optum are Preferred Provider Organization (PPO) plans and Point of Service (POS) plans. A PPO plan has a slightly higher premium and deductible, but it lets you go directly to specialists without having to get a referral from your primary care physician. You can pick from addiction care treatments in or out of the Optum network, but out-of-network rehabs will cost more.

POS plans are a less common type of Optum care that essentially combines HMO and PPO plans. With a POS, you have your own primary care physician who can refer you to rehabs in the Optum network if desired, but you are also allowed to use out-of-network services.

Does Optum Make You Pay Extra for Addiction Treatment?

Whether you pay anything for your addiction treatment depends entirely on what plan you have. For some Optum plans, you might not have to pay any extra charges to get treatment. However, with others, you can expect to pay some smaller fees. To figure out whether you will be paying any money besides your regular monthly insurance premium, it is helpful to understand a few basic insurance terms:

Copayment: A copayment is a set amount you pay for each part of addiction treatment. For example, you might pay a set amount for each therapy visit or each week of rehab.
Out-of-pocket costs: This is the total sum of your deductible, copayment, and coinsurance. It refers to all the costs you pay that Optum does not cover.

Will You Have to Get Authorization or Referrals?

Something to keep in mind when getting your addiction care from Optum is that it often requires an authorization or a referral before you can start visiting the rehabilitation center. Both of these requirements are fairly similar, but the steps of obtaining them are slightly different.

An authorization or a referral is essentially a healthcare expert looking at your situation and agreeing with your opinion that you need to get addiction treatment. A referral is issued directly to you by your primary care provider whereas an authorization is something you will get from Optum after you, your doctor, or the rehab facility fills out an authorization request form and sends it to Optum.

Whether you need an authorization or a referral primarily depends on your plan. Most people with an Optum HMO will need a referral, but those with a PPO might need an authorization. It will also depend on what type of care you want, with Optum requiring authorizations for inpatient care but not for outpatient care. This step might sound tough, but do not worry. In most cases, the authorization or referral is just a formality confirming that you do have a substance use disorder and need help. Just try to answer honestly and to explain how addiction is affecting your life, and you should be able to get the authorization or referral you need.

Explore Your Addiction Care Options From Optum

To understand more about how Optum insurance covers addiction treatment, it is helpful to learn a bit about your options. Here are some of the most common forms of addiction treatment that Optum patients may encounter.

Medical Detox

Also called withdrawal management or withdrawal treatment, medical detox is a form of medical support many patients need when getting clean from drugs. Many types of drugs cause people to form a physical dependence, and stopping these substances suddenly can cause dangerous health problems like seizures, vomiting, and hallucinations.

Optum covers all the healthcare associated with medical detox. In some cases, this coverage may include a patient taking synthetic opioids or other analogs of a drug to gradually taper down drug usage in a controlled environment. Since medical detox is often a medical emergency, it may not require any preauthorization or referrals.

Outpatient Rehab

Outpatient rehab is a type of rehab where you live at home and visit a rehab center for therapy, counselling, group meetings, and other treatments. Typically, you will start out going every day and gradually transition to visiting just a few times a week. Outpatient works well for milder forms of addiction. In cases where patients have a supportive family environment or need to attend to work or childcare every day, outpatient rehab has the benefit of letting the patient stick to his or her normal routine most of the time.

Some types of outpatient rehab do not need authorization. Instead, they fall under Optum’s ALERT program. This is a type of care where your doctors will be in open communication with Optum to discuss your healthcare needs, so you can get care without needing authorization for each visit.

Inpatient Rehab

This type of rehab is also called residential rehab. It refers to the type of rehab where you check into a facility and stay there until your treatment is finished. The benefit of inpatient rehab is that you get constant support and monitoring. You have plenty of time to spend working on fighting your addiction, and if you are tempted to relapse, it is easy to be held accountable by staff members at the rehab center.

Optum does cover inpatient rehab when it is recommended. However, the company may be more cautious about authorizing this type of rehab. In some cases, patients must first attend outpatient rehab and show that this less-intensive form of treatment is not enough to address their substance use disorders before inpatient rehab will be approved.

Medical Maintenance Therapy

For those addicted to certain drugs, like opioids, a low dosage of a synthetic drug can often remove cravings without getting the patient high or causing addictive behavior. However, like many other healthcare providers, Optum does not usually cover ongoing methadone maintenance therapy. Though Optum is happy to cover methadone use as a method of treating withdrawal and of assisting in the early stages of addiction, there is usually a time limit to how long the company will provide this therapy.

After a certain point, many healthcare providers feel that there is no medically beneficial reason to keep supplying these medications. However, new research on the subject is being done frequently, so this stance may change in the future.

Alternative Therapies

There are a variety of alternative therapies that can be used alongside more conventional treatments for addiction. Many rehab centers find that these treatments help patients lower stress levels, heal from past trauma, and improve overall wellness. Optum does offer some coverage of alternative holistic therapies like massage and acupuncture.

In most cases, Optum will not fully cover these sorts of treatments, but it will give you a discount. Those eligible for Optum’s Complementary Alternative Medicine program do not need to get a referral or authorization for these discounts.

Make It Easier to Get Your Treatment Covered

Optum insurance can be a great way of getting the care you need without having to worry about cost. However, we do understand that it can be hard to focus on things like paperwork and regulations when you are in the middle of dealing with addiction. Fortunately, there are many great organizations that can help you out. The Substance Abuse and Mental Health Services Administration runs a helpline. You can call it at 1-800-662-4357 at any time to get in touch with a trained addiction specialist who can help you find the right treatment for your budget and insurance type.

You can also get a lot of help from rehab facilities. Depending on the rehab center you talk to, it might be just as simple as giving them your name and insurance ID. Then those facilities can contact your insurance company to handle pre-authorizations and to let you know about any remaining costs. Remember that there are always people who are willing to help you navigate the complexities of insurance and addiction care. All you have to do is ask. Being open about your mental health and financial needs will make it easier to get help with overcoming your substance use disorder.

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