Whether it is you or someone you love, making the decision to get treatment for drug or alcohol addiction can be a very difficult step. It is often hard for anyone who is struggling with an addiction to be able to see life clearly, and it is more difficult to see the potential benefits of entering a rehab program. And considering the fact that not all rehab programs are made equal, finding the right program for the right problem is even more difficult.
While one may be concerned with matching the right program to the patient, it is equally as important to know how the treatment will be paid for. Drug rehab centers can be costly so for most people, finding a plan that your insurance will cover is the only way to get the help that is needed. Not all insurance companies will pay the same so learning how your insurance policy will cover your needed treatment is essential for the success of the patient’s rehabilitation efforts.
What is an EPO?
An EPO or an Exclusive Provider Organization is an insurance plan that allows the patient to only obtain treatment services from providers within their own network. Just like other plans, EPOs have their own cost-containment policies that must be followed. Regardless of the patient’s personal needs if the policies are not followed they will not pay for the plan and you may end up paying out of pocket for some pretty heavy medical expenses. For that reason it is essential that you choose a provider from their list of possible options.
When it comes to substance abuse, EPOs may be the preferred option for some people since there is no requirement for referrals from a Primary Care Physician. Choosing to go through any kind of substance abuse program can be emotionally draining and can have an impact on your professional, social, and private life. With an EPO you have the freedom to avoid many of the steps you need to get into a program. With other types of insurance you’re required to be referred by another professional or you’re required to see a physician first, but with an EPO you simply have to refer to the available list of programs and then choose the specialist or hospital you need.
Contact Your Provider First
With an EPO plan you may find it much easier to choose your provider before you look at the different facilities. You’ll need to ask what type of coverage may be available to you. Choosing from the available list of rehabilitation centers will save you valuable time and get the treatment program started ASAP.
Most insurance plans will cover some level of substance abuse treatment but it is your responsibility to make sure that the program you choose will be covered by your particular plan. This will ensure that you are not hit with any financial burden when your treatment is over.
There are three exceptions with an EPO that may allow you to choose a treatment plan that is not listed with your provider. If your provider does not have a substance abuse program available to cover your particular needs. You must be very careful with making this kind of decision though. Make absolutely sure that there is no type of treatment offered within the network plan before you look elsewhere. This does not mean that you can choose a plan you prefer over one that is available but only when you have no other option for the type of program you need.
Exceptions may also be allowed for new member if they are already engaged in a treatment program when they joined. If this is the case, the EPO may be willing to allow you to complete a program rather than to uproot you in the middle of your treatment and require you to start again in a new one.
If your situation is truly dire and you’re in need of an emergency treatment then chances are you will be allowed to take advantage of the treatment that is available at the time. For example, in the case of a drug overdose or a life-threatening accident or injury as a result of drug use you will be approved for the nearest medical treatment available. However, if the treatment is required for a longer period of time, your EPO provider may insist that you be transferred to an approved facility as soon as you’re stable.
It is very important that when you’re deciding on a substance abuse treatment plan that you speak with your EPO provider before any decision is made. Only in the case of a true emergency can you get treatment from doctors that are not within the provider’s particular network.
The guidelines for an EPO are very strict and there is little room for leeway in these types of plans. Never assume that just because a treatment you need is in the same facility as other services that they are covered by the same EPO. Make it your rule of thumb to always check before you decide.
Another reason many people may choose to use an EPO plan is because of the cost-sharing payments. Deductibles, co-payments, and coinsurance with an EPO are usually about as low as they can get. In some plans, there is no deductible or coinsurance payment needed so you can save a lot of money over the life of your treatment plan.
In light of the economic challenges that many people are facing today, it is very important that every decision you make is checked and double checked first. While many people choose an EPO because it is an easy way to save money on medical expenses, if the cost-containing policies are not followed exactly, you may be very surprised at how much more an EPO can cost you if you’re not careful.
On paper, EPOs may look and feel very similar to an HMO but there are some very distinct differences that you need to be prepared for.