Optimum Healthcare Coverage for Drug & Alcohol Addiction Treatment

Optimum HealthCare provides Medicare Advantage plans to eligible individuals. Medicare Advantage Plans replace Original Medicare Parts A and B and often include other benefits as well. The company was founded over 15 years ago to deliver quality and comprehensive benefits that are affordable and meet the diverse needs of seniors and people with disabilities.

Optimum HealthCare operates under the umbrella of HealthSun Health Plans, which is part of Anthem, Inc (now Elevance). This is one of the largest health insurance companies in the U.S. This affiliation allows them to leverage the extensive resources and expertise of Anthem to deliver high standards of care and customer service to their members.

Does Optimum HealthCare Cover Addiction Treatment?

Yes, Optimum HealthCare policies are required to cover at least as much as Original Medicare. Original Medicare provides coverage for addiction and mental health treatment as an essential service defined by the Affordable Care Act. As a result, Optimum HealthCare will also have coverage for various mental health and addiction treatment services.

The specifics of this coverage will vary depending on your plan, so it’s important to verify your insurance before committing to a treatment program. Also, Medicare Advantage plans often require you to use the provider’s network, so you’ll want to make sure you choose the rehab center accordingly.

What Are Optimum HealthCare Plans?

Optimum HealthCare offers Medicare Advantage HMO plans. These plans cover everything Original Medicare covers and include prescription drug benefits that Original Medicare members have to buy separately. The Advantage plans also generally have additional benefits not covered by Original Medicare, such as dental, vision, hearing, and fitness programs.

Other benefits of Optimum HealthCare plans include preventive services at no cost to you and a personal emergency response system that includes a monitoring device so you have access to help around the clock.

The Optimum Medicare Advantage plan may also include 30 hours each year of in home support, offering technology assistance, virtual services and companionship.

Another key feature of Optimum HealthCare plans is their emphasis on preventive health measures. They encourage you to get regular health screenings, vaccinations, and wellness visits to maintain your health and detect problems early.

A strong emphasis is placed on this proactive approach and customer service, offering support to help you navigate the healthcare options in your area and make informed decisions about coverage. The Optimum HealthCare Medicare Advantage HMO plans are designed to provide you with comprehensive care while helping manage your costs effectively.

What Types of Rehab Treatment Are Covered By Optimum HealthCare?

All insurance plans focus on covering medically necessary care, so it’s important to get a treatment plan from your doctor. Some of the covered services in your Medicare Advantage plan from Optimum HealthCare could include:

Detoxification Services: Detoxification includes medical supervision to help you safely manage withdrawal symptoms. These programs often offer medical care which includes prescription drugs to help manage symptoms.

Inpatient Rehabilitation: These treatments are offered in a residential facility or inpatient facility where you receive around the clock care and support for addiction. You’ll get counseling, fun activities, and help creating new habits and mindsets.

Outpatient Programs: Outpatient programs allow you to receive treatment during the day and continue to live at home or in a sober living residence in the evening. Some programs are highly structured and have up to 20 hours of treatment, while less intensive programs might have nine hours or less per week of rehab. These programs include individual or group therapy sessions focused on helping you live out your recovery in daily life.

Medication Assisted Treatment (MAT): Medications can be prescribed to help manage cravings and withdrawal symptoms. This support is combined with counseling and behavioral therapies to help establish your recovery long term.

Where Does Optimum HealthCare Offer Coverage?

Optimum HealthCare primarily offers coverage to Medicare beneficiaries in various counties throughout Florida. The coverage areas include counties in the center of the state bordered by Marion County in the north and Collier County in the south. They also offer concierge services in eight counties, including Marion, Orange, Sarasota and St Lucie.

The concierge services may vary in each county and may include personalized care coordinators, transportation services, home visits, wellness programs, and medication management. These services help improve your overall experience by providing you with convenient and personalized support that goes beyond traditional medical care.

How to Verify Coverage with Optimum HealthCare

Your insurance coverage through Optimum HealthCare will vary depending on your Medicare Advantage plan. Before receiving addiction services or care for mental health conditions, it is important to verify your insurance coverage.

There are several ways to do this. When you purchased your Medicare Advantage plan, you were given a member Services book that documents what your policy covers. However, these can sometimes be confusing to read. Optimum HealthCare also has a member services phone number where you can ask questions about your coverage.

The easiest and sometimes fastest way to verify your insurance coverage for addiction treatments is to work with the addiction treatment center of your choice.

The financial counselors will generally verify your insurance coverage with Optimum HealthCare and provide you with more information about the treatment center, your treatment options and what you can expect after admission.

Does Addiction Treatment Need to Be In Network?

Optimum HMO provider networks use credentialed professionals to deliver care and in most cases you need to use in network providers to get coverage.

However, on rare occasions, Optimum will cover an out of network provider. An example of when out of network services can be used is when emergency care is necessary and delaying care would be dangerous. If an emergency happens outside of your network’s service area, then in network providers would of course be inaccessible. So you would access emergency services and then when you return to your home service area you would get any follow up care from an in network provider.

To request out of network services in non emergency situations, you must ask for special approval, and these are rare. Another possibility is that you can pay for out of network care yourself rather than using insurance.

What to Do if Optimum HealthCare Won’t Cover the Cost of Rehab

If your Optimum plan informs you that it won’t cover the cost of rehab, you are not out of options. You have the right to appeal your insurance company’s decision to deny treatment. To start the process, call Optimum Member Services. You’ll find more information about the appeals process in Chapter 9 of your Optimum Evidence of Coverage (EOC) document.

To get help covering the cost without insurance you can apply for a grant from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA grants for addiction treatment are available in all states. You may also find financial assistance available through scholarships or grants from advocacy groups such as LGBTQ+ groups or through your church. Ask the rehab you are considering whether they accept these assistance program options.

Also ask if the rehab itself has a sliding scale which is a reduced fee option based on income. You can consider using a loan to pay for your addiction treatment. For example CareCredit is a company that specializes in providing credit to be used for healthcare needs. Or you could borrow money from family or friends. Because it is important to get rehab when you need it be diligent and creative when searching for your own funding options.