Overcoming addiction requires the right help and support, but drug and alcohol rehab is not often cheap. Patients frequently need assistance to pay for the help they need, and often that help comes from an insurance provider. Optima Health, an established provider with a variety of health insurance plans, offers this important coverage to its members.

About Optima Health

Optima Health is a Virginia-based insurance provider that offers individual and employer-sponsored health insurance products. All boast a strong network of over 25,000 providers as well as plans that allow for out-of-network treatment when needed. Individual and family plans are known as OptimaFit plans, while employer-sponsored plans are called Optima Vantage (HMO), Optima Plus (PPO) and Optima POS plans.

While Optima Health has a large list of insurance products, all fall under a few basic categories. First, employers and patients have the option to choose:

  • HMO – Health maintenance organization plans provide affordable medical care as long as a patient goes to a doctor or provider within the network, and referrals are not needed.
  • PPO – Preferred provider organization plans give patients the freedom to visit out-of-network providers, for an added cost.
  • POS – Point-of-sale plans merge the benefits of an HMO and a PPO into a plan that offers out-of-network benefits.

Optima health further breaks down plans based on tier level to help patients manage their healthcare costs. The tiers are:

  • Gold – A higher monthly premium brings lower out-of-pocket costs for those who visit the doctor frequently.
  • Silver – This middle-of-the-road plan has a moderate premium cost and moderate out-of-pocket costs.
  • Bronze – Designed for those who rarely seek medical care, bronze plans have low monthly premiums and high out-of-pocket costs.

Regardless of the plan chosen, patients who have Optima Health insurance products automatically have addiction treatment coverage under their plan’s behavioral health coverage.

The amount a patient will pay for addiction treatment with Optima Health will depend on the actual plan that patient has. All plans have a deductible, which ranges from as low as $1,000 to as high as $15,600. Patients may also need to pay copays or coinsurance fees for their addiction treatment as outlined in their policy documents.

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Does Optima Health Cover Drug And Alcohol Detox?

Optima Health covers drug and alcohol detox that is considered necessary by a patient’s doctors. The amount a patient will pay out-of-pocket for detox will depend on whether the detox program is inpatient or outpatient as well as what insurance coverage the patient has purchased.

For most patients with Optima Health, a deductible has to be met before coverage kicks in. After meeting the deductible, patients will pay either a copay for services or a coinsurance charge based on their plan’s documentation.

This treatment typically includes emotional and medical support to help the patient through the process of ridding the addictive substance from the body. Drug and alcohol detox is not an easy process, but with the right support and medical monitoring, it is possible. This is a critical first step in addiction treatment for many people, because only after the substance is out of the patient’s body can the real work of healing from addiction begin.

Does Optima Health Cover Inpatient Rehab?

Optima Health covers inpatient rehab. Patients with individual plans will pay between 5 and 30 percent of their costs for inpatient rehab, after meeting their deductible. The only exception is the OptimaFit Catastrophic Plan, which may cover the full cost of inpatient treatment after the deductible.

For patients with employer-sponsored Optima Health programs, inpatient treatments require a daily copay or a coinsurance charge. The daily copay is between $250 and $600 per day, with a max of between $1,000 and $2,400 per event. The coinsurance amounts are between 20 and 40 percent of the costs after meeting the deductible.

Inpatient rehab is often the second step taken for recovery. After a patient has detoxed completely, an inpatient treatment protocol will provide both emotional and medical support to prevent relapse. While in an inpatient program, individuals will receive therapies and medical support as they transition to sober living.

Does Optima Health Cover Outpatient Rehab?

Optima Health provides coverage for outpatient treatment, which is often needed after inpatient treatment or instead of inpatient treatment for those with a mild addiction. On individual plans, the patient’s out-of-pocket costs are either a copay of between $10 and $40 or a coinsurance cost of between 5 and 20 percent, depending on the plan. Patients are also responsible for their deductible.

Employer-sponsored plans break down outpatient facilities based on tiers. All plans charge either a copay of between $150 and $300 for these visits or a coinsurance fee of between 0 and 40 percent after deductible.

Outpatient drug and alcohol rehab allows a patient to live at home or in a sober living environment while still receiving therapy and treatment for addiction. This is an important starting point to learning how to live life without the shackles of addiction while still receiving the support offered through therapy.

Does Optima Health Cover Medication-Assisted Treatment?

All Optima Health insurance plans have prescription coverage, though the out-of-pocket expenses vary quite a bit. Patients who need medication-assisted addiction treatment will fill their prescriptions under this prescription benefit. The prescription benefit breaks down medications by tier, with copays and coinsurance amounts based on the plan the patient has and the tier the medication falls under. These costs vary tremendously from tier to tier and from plan to plan. They can be as low as $5 and as high as 35 percent of the drug’s cost.

One of the challenges of overcoming addiction is dealing with withdrawal symptoms, but certain medications can alleviate or prevent these symptoms. Other medications can block the pleasurable effects of substances.

Does Optima Health Cover Sober Living Houses?

Optima Health does not offer coverage for sober living houses. The company’s behavioral health coverage is limited to the medical treatments necessary for drug and alcohol rehab. A sober living house is not included in plan benefits.

Sober living houses provide a safe, drug- and alcohol-free place for an individual to live while learning to navigate life free from addiction. While some may attend outpatient therapies at a clinic while living in a sober living home, the home itself does not typically provide therapies.

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Patients who can benefit from a sober living environment may need to tap into their regular housing budgets to pay for their care in a sober living house. During the time spent in a sober living house, individuals will have the freedom to work and bring in income, which can help offset some of the costs as well.

In-Network Vs. Out-Of-Network Treatment With Optima Health

Sometimes an addiction facility that a patient wants to use is not within the insurance provider’s network. While Optima Health has a generous network, not all facilities are included. Patients must understand their options if they wish to use a non-network provider.

For patients who are on the individual plans under the OptimaFit program, only treatment with an in-network provider is covered. Those with employer-sponsored HMO plans also must visit an in-network provider for behavioral health services. PPO and POS customers can visit an out-of-network provider for a higher cost.

How To Find Drug And Alcohol Rehab Centers That Accept Optima Health

  • Contact Addiction Campuses for an immediate verification of benefits. Addiction Campuses can answer questions about insurance and addiction treatment and perform a no-obligation verification of insurance benefits on your behalf.
  • Contact the insurance provider by using the phone number on the back of the insurance card or by visiting the provider’s website. A representative will be able to match you to an in-network drug and alcohol rehab center.
  • Call the treatment center you or your loved one is interested in. The treatment center’s admissions team can answer questions about covered services.