An intensive outpatient program (IOP) is a mental health treatment program that can treat substance use disorder, depression disorders, and anxiety disorders. Does insurance cover IOP? That depends on your insurance provider, the plan, and what type of benefits it comes with. Most insurance companies have plans to cover the full or partial cost of an intensive outpatient program, or IOP for short.
Rockland Recovery Behavioral Health welcomes adults who are struggling with a mental health concern and want help in managing symptoms and triggers. Our IOP in Sharon, MA, welcomes clients who want to work with a professional therapist through group and private therapy sessions on an outpatient basis. We will evaluate your condition and create a complete treatment program to support your full recovery.
Does insurance cover IOP?
Most insurance companies will cover some or all of the cost of an intensive outpatient program. The cost of IOP depends on several factors, such as the location of the treatment center, the types of treatment programs, and the duration of the program. How much your insurance company will pay will depend on the type of policy you have.
Here is a list of insurance companies that cover IOP:
- Aetna
- Blue Cross Blue Shield (BCBS)
- Cigna
- Tuffs
- United Healthcare (UHC)
- MassHeatlh
Other medical plans that cover IOP include Medicare and government and military-funded plans.
How is IOP billed?
Administrative teams will attempt to bill your insurance provider once enrollment begins. They have specific Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes they must use to complete the billing process. If you are curious about how IOP is billed, here is a breakdown of the billing process:
- Condition code 92: This code identifies the claim for IOP services
- Revenue code 0905: This code identifies specific IOP services
- CPT/HCPCS codes: These codes are used to identify specific IOP services, such as S9484 for IOP mental health services and S9485 for IOP dual diagnosis services
- Sequential billing: This process allows staff to submit claims in the same sequence as the IOP services are provided.
- Interim billing: This procedure uses the appropriate Type of Bill (TOB) codes to process interim claims.
- Patient discharge status codes: This is a two-digit code used to identify where the client is at during the billing cycle.
Without these codes, insurance companies will not know the specific reason for the charge and may deny or limit the claim.
How much does IOP cost with insurance?
The cost of IOP can vary wildly and will depend on the state you are in, the type of treatment, and the duration. While most people do have individual insurance plans, some do not and they will need to come up with a new way to pay for the program.
How much IOP costs with insurance depends on your coverage options, but in general, your out-of-pocket costs should range from $0 to $100 per session. It depends on your insurance provider, plan, copays, deductibles, and any coinsurance. It can also depend on if the treatment center is in-network or out-of-network. This can affect the price considerably.
Copays can average between $20 and $50 per session. Deductibles for IOP can vary significantly and depend on coverage limits in the plan.
How much does IOP cost without insurance?
Without an insurance plan, IOP can be very expensive. Costs for private and group therapy sessions can range from $250 to $500 per session. Because the program length can vary between 4 to 12 weeks, the total cost of IOP can be $3,000 to over $30,000 for the entire program.
Other ways to pay for IOP without insurance are flexible payment plans, scholarships and grants, non-profit organizations, and government programs.
What factors affect coverage?
Insurance coverages can differ wildly and vary quite a bit. Several factors can affect your coverage options for IOP:
Type of insurance plan
Private insurance companies like Aetna, Cigna, and Blue Cross will affect coverage amounts as each company has different coverage options. You will need to compare each insurance plan to know exactly what they cover.
Medicare and Medicaid vary by state and eligibility, and some plans may be more generous than others.
Medical necessity
Some insurance companies require proof that an IOP is medically necessary. They may ask for recent hospitalization records, a diagnosis of a mental health condition, and recommendations from a doctor, therapist, or psychiatrist. They will also accept documentation of completion of an inpatient program or a less intensive treatment program.
Diagnosis of condition
Some insurance plans will only cover IOP if it is for a recognized mental health condition, such as depression, anxiety, and bipolar disorders. They will require a specific diagnosis from a doctor or psychiatrist; otherwise, coverage may be denied or limited.
Length and frequency of treatment
Another important factor to consider is the length and frequency of IOP. Depending on your insurance coverage, they factor in the number of sessions per week, total weeks/months of IOP, and total visits per year. They may limit the number of sessions and days per your insurance plan.
Other factors that can affect coverage include age, location, gender, marital status, claims history, coverage amounts, and occupation.
How to verify your insurance benefits
Before starting IOP, be sure to confirm your insurance plan covers the program and verify your benefits. Here is a step-by-step guide on how to verify insurance benefits:
- Find the right contact information: Call member services on the back of your card or they will list a website where you can go to verify information.
- Gather information you’ll need before the call: You will need your member ID and group number, full name and date of birth, your provider’s name, and the type of service you are asking about (IOP).
- Ask the right questions: When you call, you’ll want to ask specific questions like “Is IOP covered under my plan?” “Do I need a referral or prior authorization?” and “Is there a medical necessity requirement?” You can ask if the treatment center is in their network or out-of-network and what coverage options they have if they are.
By asking these questions and staying informed about your insurance coverage, you can better prepare for the next steps in your treatment journey. Remember, understanding your benefits is an essential part of accessing the care you need.
Advocating for yourself when verifying insurance coverage for IOP treatment is crucial to ensure you receive the care you need without unnecessary financial strain. Taking the time to ask detailed questions, understand your benefits, and clarify coverage specifics can help you avoid surprises and empower you to make informed decisions about your mental health care. Your voice is a vital part of securing the support you deserve.
Enroll in intensive outpatient treatment at Rockland Recovery Behavioral Health today
Rockland Recovery Behavioral Health is a fully accredited mental health treatment center that supports individuals struggling with mental health issues, such as depression or anxiety. We have a number of programs to support your recovery, including IOP, separate men’s and women’s programs, solutions-focused therapy, and other beneficial programs in Sharon, MA. We will work with your insurance provider and discuss payment options for any out-of-pocket costs and help you find other ways to pay for the program.
To start a conversation about your insurance plan covering an IOP program, fill out our online form or call 855.520.0531 today to schedule a consultation.