Many luxury and private-pay rehab facilities are out-of-network with most insurance plans, which does not necessarily mean no coverage is available, but it does mean the process works differently than in-network care.
Understanding how out-of-network benefits work can help you make a more informed decision about cost and facility choice.
How Out-of-Network Benefits Typically Work
Many PPO plans include some out-of-network benefit, often reimbursing a percentage of costs after a separate out-of-network deductible is met. HMO plans generally offer little to no out-of-network coverage except in emergencies. Your specific plan documents, or a direct call to your insurer, will clarify which category you fall into.
Single-Case Agreements
In some circumstances, a facility may negotiate a single-case agreement with an insurer, effectively treating an out-of-network stay as in-network for that specific case. This is not guaranteed and depends on the insurer, the facility, and the specific clinical situation.
What to Ask About Out-of-Network Coverage
- ✓Does your plan include any out-of-network behavioral health benefit?
- ✓What is the separate out-of-network deductible, if applicable?
- ✓Has the facility successfully negotiated single-case agreements before?
- ✓What paperwork is needed to submit an out-of-network claim yourself?