Kaiser Covered Drug Rehab

Kaiser Permanente is a managed care consortium that was founded in 1945 by the physician Sidney Garfield and the industrialist Harry J. Kaiser. The consortium is made up of three entities that include the Kaiser Foundation Health Plan, Inc., regional Permanente Medical Groups, and Kaiser Foundation Hospitals. Kaiser Permanente operates in Washington, DC and in the following states:

  • California
  • Virginia
  • Colorado
  • Georgia
  • Maryland
  • Oregon
  • Washington
  • Hawaii

According to its 2015 annual report, Kaiser Permanente has over 10 million health plan members, employs over 186,000 individuals, has 622 medical offices and 38 medical centers, and utilizes over 18,000 physicians and over 5,000 nurses.

The Kaiser Permanente health plan is a nonprofit health plan that has an income in the billions of dollars, making it one of the largest nonprofit companies in the United States. The quality of care offered by Kaiser is rated very highly, places a strong emphasis on preventive care, paying physician salaries as opposed to paying them per service, and attempts to minimize hospitalization expenses.

Healthcare Plans

According to its website, Kaiser Permanente offers several major types of healthcare plans:

  • Employee-based (group) health plans are marketed to businesses to provide their employees with health insurance. Depending on the business providing the plan, the cost of premiums may be deducted from the individual’s paycheck periodically. Group plans are offered directly through Kaiser Permanente. There are different options available, depending on one’s location.
    • Deductible plans have set monthly premiums and may require copays. Fees for service are paid by the participant until the deductibles are reached
    • PPO plans (Preferred Provider Organization) can be used for out-of-network providers. In-network services are typically less expensive.
    • POS plans (Point of Service) combine HMO and PPO features.
    • Out-of-area plans are utilized by individuals living outside of coverage areas. Preventive care services can be covered under these plans but other services may require copays, deductibles, etc.
  • Individual plans vary and will be associated with different deductibles, copays, monthly premiums, and other out-of-pocket expenses. Individual plans also vary depending on area but several different plans are generally available.
    • Copay plans often fully cover preventive services but require copays for other services.
    • Deductible plans allow individuals to pay fees until the deductible is met and they can then receive more extensive coverage. In some areas, preventive services may be fully covered under these plans.
    • Deductible catastrophic plans may be available for individuals with financial hardships. These plans may cover certain services completely.
    • HSA (Health Savings Account) plans have combined medical and pharmacy cost deductibles and costs are paid out of the individual’s pocket until the deductibles reached. Following that a percentage of costs are covered until the person reaches a maximum of costs pocket expense.
  • Kaiser Permanente Senior advantage plans, such as extended Medicare plans, can assist older individuals and provide significantly more options than using standard Medicare plans alone.

People who live in a coverage area can pick a specific Kaiser Permanente healthcare provider online. Plan holders don’t have to keep the same provider, as Kaiser Permanente allows individuals to change providers.

Substance Abuse Rehab Treatment Options

Different group plans may have different coverage options. Individual plans are often rated as Bronze, Silver, Gold, or Platinum, with different out-of-pocket expenses, copays, premiums, and deductibles. Plans vary on available treatment options for individuals in different coverage areas.

Finding a treatment provider that is covered under an individual’s plan for mental health services, such as therapy or substance abuse treatment, can be accomplished by using the Kaiser Permanente locator tool. Other information can be found on the Kaiser Permanente website, which provides special links to information for coverage for different types of mental health services based on the diagnosis.

The Affordable Care Act mandated that all insurance providers should provide basic insurance coverage, including coverage for mental health services, which includes at least partial treatments for substance use disorders and substance abuse issues. Kaiser Permanente, like most healthcare providers, pays for treatment services based on the concept of medical necessity. Medical necessity means that the treatment is provided by a healthcare provider, is deemed as necessary for the assessment or treatment of the specific disorder in question, and abides by the appropriate standards of care for the specific disorder. According to information provided by Kaiser, treatment coverage for substance use disorders conforms to the mandates of the Affordable Care Act and requires that medical necessity is demonstrated in order for the treatment to be covered. Depending on the individual’s plan, there may be certain copays and out-of-pocket expenses with different types of treatments.

It appears that most plans will at least offer partial coverage for:

  • Medical detox: This involves withdrawal management services with the supervision of a physician.
  • Outpatient treatment: This includes specific therapy for substance use disorders, including intensive outpatient treatment.
  • Residential treatment, when medical necessity can be demonstrated: Typically, medical necessity applied to inpatient treatment must include some documentation by a physician that the individual needs 24-hour supervision, is suffering from a severe manifestation of mental illness (e.g., a substance use disorder), or their personal situation is so disrupted by their condition that they cannot function outside of a residential treatment unit. Inpatient treatment (residential treatment) is time-limited, and for most individuals, coverage will only be allowed for a specific period of time (e.g., 30, 60, or 90 days). Treatment providers must provide documentation of goals for the treatment (true for all forms of treatment) and provide periodic updates on the individual’s progress toward meeting these goals. Under some policies, residential treatment may only be approved if the individual has failed in outpatient treatment services.
  • Transitional care: In some cases, transitional recovery services may be covered.

The extent of coverage will vary depending on the specific program. Platinum plans offer more extensive coverage compared to bronze plans. Outpatient treatment services are often approved more quickly than inpatient treatment services. For treatment to receive coverage, the individual must have a formal diagnosis of a substance use disorder as listed in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5); treatment often requires a referral from a physician, and again, it must follow the guidelines of medical necessity.

Treatments that are experimental in nature and do not have sufficient empirical evidence that qualifies them as valid treatment for substance use disorders (e.g., massage, meditation, etc.) will most likely not be covered. In addition, adjunctive therapies, such as music therapy, art therapy, etc., may or may not be covered depending on whether the treatment is a specific part of an overall program that an individual is involved in (e.g., a residential treatment program for substance abuse). Individuals should check with their insurance representative or with a customer service representative at the specific rehab center to determine the extent of their own coverage. Individuals should also check with their insurance representative regarding the types of treatments for substance use disorders that are covered.

Finally, some Kaiser Permanente medical centers may offer support groups and other programs that are targeted at mental health issues, including substance use disorders. Plan holders can check with Kaiser representatives to see if these types of services are available in their area.