In-Network vs. Out-of-Network Insurance Benefits

One of the primary obstacles to recovery for people living in active addiction is treatment costs. Because addiction is such a deeply rooted mental and behavioral health condition, successful treatment may take 30 days or more. This time frame is largely dependent on each person’s individual needs and can vary greatly from case to case. Fear of being stuck with a large bill in the end keeps many people from seeking the help they need to overcome drug and alcohol abuse, perpetuating a cycle of abuse that only has one tragic end. 

Understanding your insurance coverage and the options available to you can help to open the door to a better life beyond substance abuse. However, insurance lingo is often complex and confusing, leaving people unsure of what their plan actually covers and how to best advocate for themselves in seeking treatment. Niznik Behavioral Health is here to help. Here’s what you need to know about the difference between in-network and out-of-network insurance benefits.

What Does it Mean to Be ‘In-Network’?

In layman’s terms ‘in-network’ means there is a pre-negotiated contract in place between a service provider and an insurance company. This means those who are covered under said company can receive treatment from this provider (Niznik Behavioral Health, for example) at a pre-negotiated rate. Seeking addiction treatment from a drug and alcohol rehab center that is in-network with your insurance provider often translates to lower out-of-pocket costs for you. 

If a service provider is not in-network with your insurer, all hope is not lost. Depending on the type of insurance plan you have, you may still be covered for treatment with your chosen center. More on that later; first, let’s explain the difference between in-network and out-of-network plans.

What Does ‘Out-of-Network’ Mean?

Most major insurance providers have a search tool available that will allow you to see what physicians and specialists are within their network. If a specific clinician or treatment center is not listed through this tool or does not include your insurance company in their own list of in-network partnerships, this likely means they are out-of-network. This simply means they don’t have a pre-negotiated contract in place with your insurance company for renderance of care. Because of this your out-of-pocket costs may be higher than with an in-network provider, or your plan may not cover treatment costs at all. It all depends on your type of plan.

How Do Providers Become In-Network?

Joining an insurance network is more than just being added to a list of providers. The process is thorough and meticulous, ensuring each provider meets or exceeds specific standards of care and other insurer requirements. After applying to join an insurance network, providers are subject to an inspection that includes verification of all credentials and certifications. 

Niznik Behavioral Health is in-network with some of the nation’s largest insurance providers including Cigna, Humana, Aetna, Blue Cross Blue Shield and more. We are certified by the Joint Commission and SAMHSA and committed to providing the highest quality of care to each client across our entire family of treatment centers. You can learn more about our facilities here.

Insurance Plan Types: HMO, EPO, and PPO

Unless you have to use your medical insurance often, odds are you don’t know what type of plan you have off the top of your head. Most people are either insured through their employer, a public assistance program, or self-pay. No matter how you are insured, finding out what kind of plan you have is relatively easy: most insurance cards have the information on the front or back panel. It will say HMO, EPO, or PPO. Once you’ve located that information it can help determine your treatment options with Niznik Behavioral Health or any provider.

Here’s what those three letters mean:

HMO: an HMO, or Health Maintenance Organization, is a medical insurance group that offers healthcare services at a fixed price. The most affordable of the insurance plan options, coverage through and HMO comes with lower premiums at the cost of flexibility of care. With an HMO plan you must seek treatment through an in-network provider or risk having your coverage denied. This also extends to specialists like those who treat behavioral health conditions like drug and alcohol addiction. Your HMO provider can require a referral from your in-network primary care physician before you can go to an in-network addiction treatment center.

EPO: an EPO, or Exclusive Provider Organization, is another insurance plan that restricts your treatment options to providers that are in-network with your insurance company. These plans are a kind of middle ground between HMOs and PPOs because they are somewhat less costly than a PPO but have greater flexibility than an HMO. EPO plans don’t require a referral before you can get specialty care, saving your time and money.

PPO: a PPO, or Preferred Provider Organization, puts the power in your hands. As with the previous coverage plan options PPOs offer in-network treatment options at a pre-negotiated (often lower) fixed cost. However, they come with the additional flexibility of being able to get treated by an out-of-network provider. This option is typically more costly to you, but in some instances this may open the door to a better level of care not otherwise available. Niznik Behavioral Health, for example, offers a client-first approach to care and individualized treatment plans that may not be available through your in-network options like state-funded rehab centers.

Now that you have a better understanding of your insurance plan and treatment options, give Niznik Behavioral Health a call to take the first step in your recovery. If you still aren’t quite sure about your insurance coverage, we can help. Our admissions team is knowledgeable, experienced, and ready to answer any questions you may have.


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