Prime Health Services Coverage for Drug & Alcohol

Prime Health Services is a network health provider offering access to health providers in the United States. As one of the oldest provider networks in the country, it’s used by a large number of private, third-party administrator, and employer-provided insurance policies across the United States. It also offers a network of over 600,000 in network healthcare providers including hundreds of rehab centers and thousands of therapists.

That gives you plenty of choice if you’re looking for substance use disorder treatment or coverage for any drug and alcohol related services. However, Prime Health is not an insurance provider and does not offer health plans. Instead, it offers network access to your primary health plan, so you can reduce your out-of-pocket costs.

Does Prime Health Services Cover Drug & Alcohol Treatment

Prime Health Services includes a network of some 600,000 healthcare providers. These include addiction treatment centers with inpatient and outpatient services, detox services, and behavioral therapy.

You’ll also find counseling, group therapy, and many other services. For example:

Essentially, Prime Health includes a wide range of health treatment facilities and options for drug and alcohol treatment in its network. Of course, you’ll still have to check with your health plan to see what is actually covered.

What is a PPO Network?

A Preferred Provider Organization Network is a network of health care providers including doctors, hospitals, emergency care rooms, clinics, facilities, therapists, and counselors. The only thing they have in common is that they’ve all agreed to provide care at lower rates via a single network.

This allows that network to negotiate preferred patients for the network and the network to negotiate preferred rates for the patients. This means the doctors get more guaranteed patients and you get lower rates. Of course, you do have to be in the network to qualify. And, that means having an insurance plan that is part of the network.

Often, the disadvantage of a PPO is that you can’t always go to the treatment centers you want.

However, with a large network like Prime Health Services, where you have a choice of some 600,000 health service providers, it’s extremely easy to go to an in-network provider. Still, you’ll want to do your research to see what your options are for in-network addiction treatment in your area. Attending an out of network service can result in you paying almost all of the costs or even all of the costs. Depending on your insurance provider, out of network fees might be additional charges per day, additional coinsurance, or even no coverage. So, if you have a PPO plan, you’ll have to do due diligence when shopping for a treatment center.

Who is Prime Health for?

Prime Health focuses on Medicaid which means that you are almost guaranteed to have access to the Prime Health network if you are on Medicaid. However, the organization also offers network access to private insurers (E.g., if you are self-employed and are insuring yourself), to employer-provided plans, and in some other circumstances. Therefore, if you have an insurance plan with your boss, you might be able to access and use the Prime Health network.

Which Insurance Providers do Prime Health Work With?

Prime Health network primarily works with Medicaid, Medicare, and employer-provided health plans. This means you might have a large insurance provider like Cygnet. You might also have something like Tricare West or Molina.

However, you might also have any of a number of smaller and less well-known plan options. You’ll just have to check if your provider works with Prime Health directly. Here, you can normally contact your health plan provider, check what’s included via your existing health plan contract, or log into your HR portal at work to see what’s included.

Here, you might not get the name of the network you’re working with. However, you will have access to a searchable database of health providers in your network. This means you can generally get a good idea of who is in your network just by looking things up.

Here, it’s important to keep in mind that just because you’re working with employer-provided health care doesn’t mean your employer can see what you’re getting treatment for. Your employer never gets to know about your private medical needs. If they ask, they are breaking the law. Therefore, you can ask for rates, deductibles, and information on how to search your provider network without them getting to ask what it is for.

Why Work with an In Network Addiction Treatment Center?

PPO networks like Prime Health offer a lot of advantages if your health plan is in the network. This means that, wherever possible, you typically want to work with an in network plan. However, the exact advantages of doing so largely depend on the plan itself, including your deductibles, your out of network rate, if your plan even allows you to go to an out of network provider, and other details. Some of the advantages of going to an in network provider can be:

• Reduced Costs – You typically get a negotiated reduced rate when you choose an in-network provider. That may be 30% or more. In addition, you’ll typically pay a lower deductible and a lower coinsurance. For example, it’s not uncommon to see differences of as much as 20%+ for coinsurance between in network and out of network providers.
• Approval – Going to an in-network provider often doesn’t have the same preauthorization requirements. This means you can go to treatment faster and with less hassle than if you have to wait for an out of network provider to be authorized.
• Convenience – You’ll have a list of providers to choose from. These will typically already be approved by your health plan. In addition, they’ll normally already work with your insurance plan. This means you’ll save time and hassle on checking whether they do or not.

Here, it’s important to keep in mind that there’s a big difference between searching your health plan’s database and your network’s database. Just because a healthcare network works with your health plan doesn’t mean every health provider on that plan accepts your insurance. You’ll still want to start your search from your health plan’s database.

Getting Help

If you or a loved one is struggling with substance use disorder, it’s important that you get help. Your insurance will cover at least a portion of that care. And, your PPO network like Prime Health ensures that your treatment is as cost-effective as possible. If you’re ready to get help, reach out to your health plan, check which providers are on your network, and then verify that they accept your insurance. Often, you will need pre-authorization and a doctor’s referral. Otherwise, there should be no differences between getting treatment for drug and alcohol use and for any other medical problem.