You’re ready to seek treatment for an addiction. You have so many questions. Which are the most effective treatment options for me? How will I pay for it? Does Optum cover drug and alcohol rehab? What services do they cover?

Whether you’re the one suffering from the addiction or it’s your loved one, know that you’re not alone.

According to SAMHSA, in the US, over 20 million people suffer from substance abuse. That’s nearly 1 in 12.

According to the CDC, 10% of people age 12 and up have used illegal drugs in the past month.

Addiction can begin early and may continue well into adult life. Without effective treatment, few substance abusers are able to find and stay on a healing path to lasting recovery.

If Optum will help cover the costs of treatment, you need to know. You don’t want to pay more than you have to while getting the help you so desperately need.

To better understand what Optum insurance for rehab will and will not cover, we’ll answer the following questions:

  • What does Optum rehab insurance cover when you enter treatment for addiction?
  • What, if any, treatments need prior authorization from Optum insurance before you enter a drug rehab?
  • What, if any, restrictions, are there when you seek Optum healthcare for your addiction?

Please Note: Coverage varies based upon individual plans. Additional restrictions may apply. This is intended to help you better understand coverage options with Optum. You should additionally refer to your policy.

If you need assistance in better understanding your individual Optum policy, working through financial barriers or finding effective treatment centers, our compassionate professionals are ready to assist you. Just call our free, confidential helpline.

Identifying Your Optum Insurance Network

The first step is determining if you have an Optum HMO or a PPO:

The Optum HMO requires you to choose a PCP (primary care physician), who will likely be your family doctor. This doctor then refers you to specialists and facilities that are in your HMO’s network. If you have an HMO, then seeing a doctor or going to a facility outside your network may cost you a lot more or not be covered at all.

The Optum PPO or POS will have a preferred network. You have more freedom in which doctors and facilities you use. But if you go out of network, you’ll pay more.

To get the most coverage stay in your network.

Determining What You Pay For Treatment with Optum Insurance Coverage for Rehab

Even if you have great coverage, you’ll likely be responsible for some of the bills associated with your treatment.

If your Optum plan has a deductible, then you will need to meet it before coverage begins. The deductible must be paid each year so try to schedule rehab so that you don’t have to pay 2 deductibles.

Some Optum plans will also have a copay/coinsurance, where you pay a certain flat fee for each visit, day of treatment or the whole treatment and Optum picks up the rest. For example, in an inpatient stay, you may pay $185/day and Optum will pay the difference.

Once you meet your maximum out of pocket limit, Optum will pay the rest for covered services.

Prior Authorization Requirements

All non-emergent inpatient services require a prior authorization from Optum. Your doctor will help you obtain it. Optum has a different kind of authorization program called ALERT for outpatient services. They don’t require traditional prior authorizations for many outpatient services, but do require ongoing communication with your doctors regarding your progress.

What’s Typically Covered by Optum Insurance for Rehab?

Optum prides itself on its extensive programs and research related to helping people with substance abuse.  They work with their network of providers to apply this research and offer their members the most effective, scientifically-proven options. This does mean that you will get respected care, but may mean that they won’t cover treatments that they consider ineffective or investigational.

Diagnosis – In this first phase of treatment a doctor or doctors will talk with you and run tests. Their goal is to determine the severity of the addiction and the best course of treatment. They’ll then write doctor’s orders for those treatments. This is covered by Optum.

Medical Detox – During this phase you’ll remain under medical observation for several days while the drug breaks down in your system. You could experience dangerous withdrawals so 24/7 monitoring is necessary. Optum typically covers medical detox.

Drug Replacement Therapy – In this therapy the drug of choice is replaced with a more manageable, “less harmful” drug which is prescribed by a doctor who reduces the dose over time. Optum will typically pay for this as part of a more comprehensive treatment program.

They won’t pay for maintenance during which the addiction sufferer remains on the replacement drug long term as a harm reduction method. Optum will pay for treatments that work to help the person become drug free, but not programs that allow the addicted to remain addicted to a substance.

Outpatient Rehab – Outpatient rehab can involve intensive outpatient, which is several days a week for several hours a day of counseling, classes, group therapy and other treatments. Outpatient can also be done over a longer period of time with less intensity. Optum covers Outpatient.

Inpatient treatment can last 30, 60 or even 90 days in either a hospital like setting or home-like setting. Most plans will cover some inpatient, although longer stays may not be covered. Optum will require you to attempt outpatient treatment options first and may be selective about which options they want you to try.

Support is Just a Phone Call Away!

We at Adrugrehab.org know how overwhelming it can be to try to make this journey on your own. This is why we offer a free, national helpline, confidential and available to you 24/7, manned by our licensed counselors and other mental health professionals to give you advice, answer your questions, and provide confidential referrals to the best treatment facilities your insurance will cover.

Pick up the phone and let us help you get on the path to lasting recovery today!