Oscar Insurance Coverage for Drug Rehab & Addiction Treatment

Oscar Insurance was started in 2012 and is a healthcare technology company that uses proprietary software and an online platform to connect with its customers. They have 1.5 million members in 18 states.

Oscar focuses on providing virtual medical care, so customers are encouraged to use the website or app to find providers, get prescriptions refilled, and contact their Virtual Care Team. The company also has a limited network of in person care providers.

Oscar Insurance prioritizes diversity, inclusion, and belonging. It is a majority female company. In addition, they offer yearly grants of $150,000 to organizations across the United States that are committed to serving underserved communities.

Does Oscar Insurance Cover Addiction Treatment?

Oscar plans do offer some coverage for mental health treatment and substance use because they are sold on states’ Insurance Marketplaces. However the company focuses on virtual care, and the in person provider network is quite small.

Even though Oscar works with Optum to provide mental and behavioral health care, it can be challenging to find an addiction treatment provider that takes Oscar in many areas.

Mental healthcare is more likely to have available in person providers than substance use treatment. However, this varies dramatically depending on where you live. You can check the available providers in your area without signing up, which is helpful if you’re considering an Oscar Plan.

Coverage for treatment is usually based on your doctor’s recommendations. If you have Oscar coverage, work with your primary doctor to determine an appropriate treatment plan for your needs.

What Are Oscar Insurance Plans?

Oscar offers insurance plans on the state Insurance Marketplace in 18 states. These plans have metal tiers that help you understand what percentage of your care they will generally cover.

For example, a Bronze plan covers only about 60% of the cost of care, but you pay a much lower premium. A Gold plan covers 80% of the cost of care but has a higher monthly premium. A Silver plan balances the two by covering about 70% of your medical costs with a monthly premium in between Bronze and Gold.

There are also different types of plans available from Oscar, depending on the state you live in. There are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), and Point of Sale plans (POS).

The differences between these plans are focused on two areas: Can you get care outside the network and do you need a referral to see a specialist (such as an addiction counselor)?

An HMO and EPO require you to stay within the plan’s provider network. A PPO or POS allows you to get coverage out of network, but your deductibles and copayments will be much higher because the plan covers much less of the cost of care.

An HMO and a POS plan both require you to have referrals to specialist care, even if the specialists are in network. A PPO and EPO give you the freedom to go to any specialist in the provider network without a referral.

Because an HMO has the most restrictions, it tends to have the lowest monthly premium. A PPO has the fewest restrictions, so they tend to be more expensive each month.

Does Oscar Cover Mental Healthcare?

Oscar offers a variety of mental healthcare options. They have in person mental healthcare in their network in many areas. If that’s not available or you prefer virtual care, you can access Doctor on Demandand use your Oscar ID to sign up for an account.

You can also search for a mental or behavioral health provider on Optum’s website using the code OHP or by calling Optum at (877)-855-1317.

Optum also offers an emotional support hotline that’s free of charge and available 24/7. Anyone can use it, whether or not they have coverage through Optum. The number is (866) 342-6892.

Finally, the Perks area of your member account on Oscar’s website gives you access to the Calm app for 40% off the normal annual subscription.

What Special Benefits Are Available From Oscar Insurance?

Because Oscar focuses on offering virtual medical care and support, they have a variety of unique benefits.

For example, Oscar’s plans include Oscar Care. This program allows almost all members to get free virtual urgent care visits. Some Oscar members will also have access to free virtual primary care visits for those 18 and older as well.

Oscar allows members to order prescription refills virtually and have them delivered by mail. Many common medications cost only $3 per refill.

The company also refers people to visit WeConnect’s free Online Support Meetings. These meetings allow you to talk about grief, mental health, substance use, and more. There are general meetings and specialty meetings with a specific focus.

If you have a Diabetes Care Plan with Oscar, you can enroll for free in Livongo, which provides resources for those living with Diabetes.

What Outpatient Rehab Does Oscar Cover?

Most of Oscar’s resources are focused on mental healthcare. However, in some areas they also have in network providers that offer outpatient addiction treatment.

Outpatient programs allow you to live at home or in a sober living environment while you attend treatment during the day. Options include partial hospitalization programs (PHP), intensive outpatient programs (IOP), and regular outpatient (OP) programs.

Partial hospitalization programs allow you to attend treatment during the day and return home at night. They typically run 4 to 8 hours a day, three to four days a week, and last between 30 and 90 days.

Intensive outpatient programs often offer 9 to 20 hours of treatment per week, spread over 3 to 5 days, with a total of 90 days of treatment recommended.

In general outpatient programs, you may be seen at a clinic or rehab facility one or more times a week. Group counseling and education on addiction and relapse prevention are typically provided, and when needed, individual sessions may be offered.

Once you finish treatment, you may have access to aftercare resources such as peer support and social services.

What Inpatient Addiction Treatment Does Oscar Cover?

Inpatient addiction treatment is very intensive. You may have to spend several weeks at a facility. For these reasons, it’s important to make sure that it’s the right treatment for you. Typically, your doctor will use an American Society of Addiction Medicine (ASAM) assessment to determine whether you need residential care or can start with an outpatient program. Then they will call Oscar to get their prior approval for coverage.

If you find yourself in residential rehab expect to be in scheduled programming for the duration of each day you spend there. You may get a little free time to attend to self care and chores. The rules and the structure are as much a part of treatment as the programming itself. The programming focuses on building skills to help you avoid relapse.

You may have to go through medical detox before you can participate in residential rehab. In residential detox, trained medical professionals supervise your withdrawal from substances like alcohol and benzodiazepines and opioids. Their goal is to prevent the harm that withdrawing from these substances can cause to your health.

Does Oscar Cover Methadone & Suboxone (MAT)?

MAT stands for medication assisted treatment. If it’s right for you, Oscar may be able to cover it. With MAT, medical professionals use FDA approved drugs to treat you for alcohol or opioid dependence. Medications can be used to get you through withdrawal and then help you stay in recovery. In the case of opioid use disorder they can also be used as maintenance treatment.

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

If you can’t find a drug rehab that’s in network through Oscar start by calling Optum. Since Optum is the company that manages behavioral health benefits for Oscar they may be able to find a provider or make an exception for you.

If you can’t get an exception you have a few options. You might consider traveling the distance to a facility they do cover. If you decide to do this you’ll want to make sure the facility will take you. You should also get prior approval from Oscar.

Next consider ways to cover treatment yourself. Many non profit rehabs have income based sliding scales. Some will take you without regard for your ability to pay. Some faith based organizations offer residential rehab for free. There may also be state and county level resources that will work with you.

You may also be able to get referrals to alternatives that are cheaper. If your counselor is the one referring you to treatment they can assess if a more affordable alternative is appropriate. People with opioid use disorder can sometimes avoid residential rehab if they get on MAT. Others may be able to manage with a partial hospitalization program while living in a sober house.