Will Humana Insurance Cover Drug Treatment?

Humana insurance is one of the largest publicly traded health insurance providers in the country. The Humana network includes over 350,000 medical providers, participation at more than 3,000 hospitals, and the use of nearly 50,000 pharmacies across the United States.

Substance Use Disorder Treatment Coverage

As a result of the Affordable Care Act, all insurance providers must provide some benefits for mental health and behavioral healthcare services. Even though news reports indicate that Humana is no longer active in the Affordable Care Marketplace (although it states that some of its plans may be available through the Marketplace on its website), it must abide by these regulations. This means that all of the Humana healthcare plans offer some form of substance use disorder coverage. According to its website, starting in 2018, Humana will no longer offer individual healthcare plans and will only participate in group healthcare plans.

Currently, Humana offers an extensive array of healthcare plans. In order to appreciate the variety of healthcare plans offered by Humana, one needs to go on their website and look at all the different plans they offer. Humana offers a variety of both HMO and PPO healthcare plans.

An HMO plan (health maintenance organization) allows access to certain physicians, treatment providers, and hospital within a specific network. The network has agreed to provide lower rates for individuals who are members of the plan, and coverage is only guaranteed if you see a provider within the HMO network. Some HMO plans offer some opportunities to also see non-network providers.

HMO plans may require the patient to select a specific primary care physician within the plan or network as well as a referral from a primary care physician to see specialists. Many plans may not cover costs associated with providers that are outside the network. The premiums for HMO plans are generally lower than for other plans, and there is usually no deductible or the deductible is negligible. A deductible represents a certain amount of total costs toward healthcare coverage that an individual must pay out of pocket before the insurance policy kicks in.

A PPO health insurance plan (preferred provider organization) provides more flexibility when it comes to picking a specific treatment care provider or hospital. PPOs are more likely to pay costs for non-network providers, although they may cover a lower percentage of the cost. Premiums tend to be higher with PPO plans, and these plans most often have a deductible.

In addition to deductibles, most insurance policies have copays. For example, an 80/20 copay plan indicates that the insurance company is responsible for 80 percent of the insurance costs and the patient is responsible for the other 20 percent.

Basic Humana plans include:

  • Humana Portrait Plans: These plans are designed to provide the types of benefits that large corporations provide employees. When the services of in-network providers are used, the plan typically pays 80 percent of insurance expenses, and the individual is responsible for 20 percent. In-network deductibles range from $1,000 to $2,500 for a single person.
  • Autograph Plans: These different plans allow for more flexibility in the types of benefits offered, and benefits are dependent on the specific type of plan. Deductibles range from $2,000 to $5,000 for individual coverage, and there may be a lifetime maximum coverage for these plans.
  • Monogram Plans: These plans offer low-cost coverage with higher deductibles and copays; deductibles can be $7,500 or more for single coverage.
  • Medicare Plans: These plans are designed to participate with Medicare and offer Medicare benefits.

Substance Use Disorder Services Covered by Humana Insurance Plans

Humana insurance plans provide coverage for individuals who have substance abuse issues. Treatments that fall under the coverage include:

  • Withdrawal management (medical detox): Depending on the specific type of substance use disorder in question, Humana will cover at least part of the cost of inpatient or residential withdrawal management programs. In some cases, individuals may need to opt for outpatient withdrawal management, such as for withdrawal from marijuana or from other substances that do not fit the definition of medical necessity for inpatient treatment. Individuals being admitted to inpatient facilities often require that their treatment providers submit detailed treatment plans, expected dates of admission, expected discharge dates, progress updates, etc., in order for approval to be given.
  • Outpatient treatment: Depending on the policy, Humana will cover at least part of the cost for various outpatient treatments, including medically assisted treatments, therapy, and other treatments deemed as medically necessary.
  • Follow-up treatments: Again, depending on the policy, specific types of follow-up treatments interventions may be covered.

The deciding factors that determine what treatment will be covered and the amount of coverage administered will be determined by:

  • The notion of medical necessity: Insurance companies rely heavily on the notion of medical necessity when determining coverage. Medical necessity is determined through an examination of the empirical research evidence regarding specific types of treatment, the utility in the treatment of that particular disorder or disease, and whether or not less expensive treatments can provide equivalent results. Most insurance companies follow specific guidelines when they determine which types of treatments are medically necessary in individual cases, but they can be influenced by referrals written by a competent physician.
  • Whether the service contributes to the treatment: For individuals who are involved in inpatient or residential treatment centers, some services may not be fully or even partially covered by Humana insurance. These may include things like housekeeping services in residential treatment facilities, treatments that lack empirical evidence regarding their effectiveness (e.g., rapid detox), and certain types of complementary or alternative activities, such as music therapy and art therapy.
  • Medications: Humana will typically cover the cost of medications if the medication is approved for the use it is being administered for. Some medications used in substance use disorder treatment programs that do not have sufficient empirical evidence for treating certain aspects of withdrawal management or recovery may not be covered.

To ensure a policyholder receives maximum coverage, it’s important to do the following:

  • Take the time to fully understand one’s policy and benefits.
  • Be referred for treatment by a physician or other authoritative medical professional. Physician referrals typically carry the most weight when referrals are made for inpatient or residential treatment.
  • Work with the treatment center’s intake personnel to make sure that the treatments one will receive are covered under the specific insurance plan. These intake workers are very adept at determining what services are covered.
  • Discuss any questions or concerns with a customer service representative at Humana.

Click below to learn about some of the major insurance providers with policies that may cover drug treatment or ancillary services.