HMO Insurance Coverage for Drug and Alcohol Addiction Treatment

Individuals or families under an HMO insurance plan must pay a monthly or annual premium to gain access to medical services within the organization’s health practitioners and facilities. However, you are only limited to receiving medical care from providers within the network. Though HMOs don’t cover out-of-network services, some exceptions include emergency care and dialysis. In some cases, individuals under cover of an HMO plan might have to live or work within the network’s coverage area.

If you receive urgent care outside your network’s coverage area, your HMO provider might cover the expenses. However, if you receive non-emergency out-of-network care, you will have to pay out-of-pocket. This is because the Affordable Care Act of 2020 requires all HMO insurance providers to maintain the maximum out-of-pocket cap, which is 2022 stands at $8,700 for individuals and $17,400 for family plans.

In addition to low premiums, there are no or minimal deductibles with an HMO insurance plan. The deductible is the amount you spend on covered health services before your insurance provider starts covering medical costs. Though there are little to no deductible payments, your insurance provider will charge you a co-pay for each clinical visit, prescription, or test. Co-pay charges tend to be low under an HMO plan, usually at $5, $10, or $20 per service, which minimizes the overall cost of out-of-pocket payments.