Using Health Insurance for PHP
Health insurance will generally cover all or part of the expenses of a PHP. Specifics will vary from plan to plan, so check with your insurance provider prior to enrollment to learn exactly what you will pay out of pocket.
What Is a PHP?
A partial hospitalization program (PHP) is an intensive addiction treatment option that still allows clients to live at home or in a sober living home. These programs are generally time-limited, rigorous, and allow for substantial clinical attention during the day.
You can expect to receive treatment in a hospital-like setting during the day, anywhere from three to five days per week. Often, you’re at the treatment center for about six hours per day.
PHPs are highly structured. They offer group and individual therapy, and you’ll learn the skills you need to successfully recover from substance abuse. Throughout the course of your care, you’ll connect with social workers, nurses, psychiatrists, and other health care personnel.
Does Insurance Always Cover PHP?
It’s likely that at least part of your PHP treatment will be covered, but you may need to meet certain requirements your provider outlines. For example, you may need prior authorization from your primary care physician (PCP) before coverage for your PHP is approved.
As of 2014, the Affordable Care Act (ACA) mandated that substance use disorders be included in the 10 essential health care benefits. Policyholders have more access to mental health and substance abuse treatments as a result.
Healthcare.gov says that all insurance plans must cover the following services:
- Treatment for substance use disorders
- Counseling, psychotherapy, and other behavioral treatments
- Behavioral and mental health inpatient services
The ACA also stipulates the following:
- Pre-existing conditions, including substance use disorders and mental health issues, must be covered.
- Your plan must cover mental health or substance use disorder treatment when your coverage begins.
- As they are essential health benefits, insurers cannot put yearly or lifetime caps on mental health or substance use disorder coverage.
Insurers are also required to provide parity protections. Mental health and substance use disorder treatment limits cannot be different than those that exist for physical or surgical treatments. There may be guidelines related to:
- Management. Prior authorizations may be required for certain services.
- Certain expenses. You’ll still be required to cover copays, deductibles, and other out-of-pocket expenses, like coinsurance amounts.
- Overall amount of treatment. Most plans place a limit on the number of sessions during a certain time period, such as each quarter, or a total number of days in treatment that are covered.
How Coverage Can Differ
Again, most insurance companies will cover a PHP, but they often require preauthorization. Your state’s laws may influence how your provider handles your case. Each provider may also handle the preauthorization process differently.
Some may ask you to give your insurance information to a potential clinic. The clinic will then call the insurer directly to see if they cover the PHP you are interested in. You can usually get a general estimate of how much will be covered and how much you’ll be expected to pay out of pocket.
You’ll receive higher levels of coverage if you opt for an in-network provider. Your insurance company may be able to give you referrals to providers they cover.
You can still access care from out-of-network providers, and many insurance plans still offer some level of coverage for these options. Expect to pay more out of pocket if you choose an out-of-network provider.
Differences Between Coverage for a PHP vs. an Inpatient Program
Inpatient programs are different from PHPs in that they require clients stay at the treatment facility 24 hours a day. As a result, inpatient addiction treatment programs are more expensive than outpatient options.
Health Affairs outlines a few factors that could influence how your insurer may pay for your services if you choose a PHP versus an inpatient program. The variables below apply to people who use Medicare to pay for services. They can give you an idea of what you can expect from other insurance providers.
- Inpatient programs are paid differently. Medicare will often pay for all services rendered in one lump sum. The payment covers physical care, treatment, staff, room and board, and medications.
- Your case is compared to other patients who face the same health issue you do. The plan will cover the average number of days others have spent at a hospital for the same condition.
- Hospitals do not receive more money if they decide to give you extra services on their own.
- Payment will also cover services you have received 72 hours before checking into an inpatient program.
- Outpatient programs are typically paid solely based on the services you receive.
- Services are first classified, and hospitals get one payment for the various treatments received per visit.
- Some services may not be covered if Medicare or your insurance provider decides that it may be safer for you to receive the service only if you are part of an inpatient program.
You will still be responsible for copayments whether you choose inpatient treatment or a PHP. Some insurance providers may use an inpatient program to determine whether or not you remain eligible for other services later on.
Oftentimes, insurance companies require that you first attempt outpatient treatment before inpatient treatment will be covered. Since a PHP is an outpatient program, you are more likely to initially receive coverage for this than an inpatient rehab program.
Is a PHP Right for Me?
A PHP can work well if you need a rigorous treatment program, but still want flexibility to live at home.
To determine the right plan for you, you’ll need an assessment from a prospective treatment center. The clinician will assess your situation and recommend a course of care that is appropriate.
The National Institute on Drug Abuse (NIDA) says that substance use treatment should be customized to your unique needs. If you enroll in a PHP, it shouldn’t feature a cookie-cutter approach to recovery. It should be tailored to your individual situation.
With careful planning and help from a doctor or addiction specialist, you can find the best program to fit your needs.