Optum Insurance for VA Drug and Alcohol Rehab

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Published June 24, 2021 

 

If you’re a veteran who is seeking treatment for a substance use or abuse disorder, you may be wondering what your insurance options are. Due to their service in the military, veterans have access to a variety of insurance options through the Department of Veteran Affairs (VA). Optum insurance is one of the many resources for veterans to get health coverage.

Optum insurance is part of UnitedHealthcare, one of the nation’s largest health insurance companies, and works as the third-party administrator for the VA to provide veterans with insurance coverage for healthcare through the VA’s Community Care Network.1 Optum can help veterans get the rehabilitation they need at little to no out-of-pocket cost. Of course, coverage does depend on one’s location, eligibility, insurance plan, and the intensity of care needed.

Table of Contents

What is Optum?

Optum is a third-party administrator for the VA’s Community Care Network, helping nearly 6 million veterans find quality healthcare services in their community.1 Veterans don’t enroll in Optum. Rather, they interact with it when they utilize VA Community Care Network services. The Community Care Network is a VA program that connects veterans with private healthcare facilities when their medical needs cannot be met by a VA facility. Optum works to facilitate the relationship between these community care partners and the VA. Optum also helps process claims, answers questions from the VA and its providers, and supports VA centers and staff.1

What States Does Optum Service?

Optum serves as the third-party administrator for the VA Community Care Network for 3 regions in the United States. These regions cover states in the Northeast, Southeast, and Midwest as well as the District of Columbia and a few territories:4

  • Region 1 (Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, Vermont, Virginia, and West Virginia)
  • Region 2 (Illinois, Indiana, Iowa, Kansas, Kentucky, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin)
  • Region 3 (Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, Puerto Rico, South Carolina, Tennessee, and U.S. Virgin Islands)

Optum Eligibility Requirements

Optum isn’t a health insurance provider; it’s a third-party administrator. Veterans within specific regions who are eligible to use the VA’s Community Care Network are eligible to use Optum. Veterans, but not their families, may be eligible to use Community Care Network if any of 6 conditions are met. A VA provider typically determines eligibility.

Veterans must receive prior approval from the VA before seeking community care to avoid incurring costs.2 Your eligibility for community care will depend on your specific health needs or personal circumstances. However, you must be either enrolled in VA healthcare or eligible for VA healthcare without needing to enroll to receive care through the VA. This is the only way a provider can determine your eligibility for community care.

You must meet one of the following criteria to be qualified to use community care:2

  • There is no full-service VA medical facility in the state or U.S. territory where you live.
  • Community care is in your best medical interest.
  • Care within designated access standards cannot be provided to you at a VA medical facility or by a VA provider.
  • You qualify under the “grandfather” distance eligibility provision for the Veterans Choice Program (VCP):
    • You must be eligible under the VCP’s 40-mile criterion and continue to reside in a location that would qualify you under this criterion; you live in North Dakota, South Dakota, Montana, Alaska, or Wyoming; or you live in another state and received care between June 6, 2017, and June 6, 2018 and required care before June 6, 2020.
  • The service you need isn’t provided at a VA medical facility.
  • Medical service line doesn’t meet the VA’s quality medical standards.

For more questions regarding your eligibility for the VA’s Community Care Network, click here or contact your local VA.3

How Does Optum and VA Community Care Work?

The VA Community Care Network is a program that helps veterans get the care they need, especially when that care cannot take place at a VA facility for whatever reason. The Community Care Network works with community providers (those outside of the VA system) in 6 regional networks to ensure that veterans receive timely, quality care. Optum is the third-party administrator in 3 of these 6 regional networks.4

For example, if you needed drug and alcohol rehab treatment and were eligible to receive community care through the VA, the VA would work with Optum to purchase/contract out your rehabilitative treatment through a community provider, such as American Addiction Centers (AAC). AAC would provide your services, and Optum would direct all billing, questions, and care coordination between AAC and the VA. While you may be required to pay a copay if your substance use or abuse disorder isn’t related to your service, you will receive all other claims and bills the same way that you would for services rendered within the VA system.5

Does Optum Cover Rehab?

Treatment for mental health conditions (including substance use and abuse disorders) is considered an essential health benefit that must be covered by health plans under the Affordable Care Act.6 Most forms of insurance for veterans — including VA health care benefits, TRICARE plans, Medicare, Medicaid, Marketplace plans, and private health plans — will provide coverage for rehab in some capacity. Generally speaking, most health plans cover part, if not all, of the cost of rehab for substance abuse for veterans and active-duty service members. However, it’s always best to speak with your insurance provider, as coverage may vary based upon one’s needs and insurance plan.

If you are a veteran or active-duty service member seeking rehab for substance abuse through the Optum Community Care Networks in Regions 1, 2, or 3, your treatment will most likely be covered.4 Be sure to verify your coverage through your health plan before seeking treatment to avoid any surprise medical bills or unexpectedly high costs.

Does Optum Cover Medications?

If medication is prescribed for treatment of a substance use disorder through the Optum/VA Community Care Network, it will likely be covered in some capacity under your health plan.4 For medication-assisted treatment (MAT) for substance use disorders, the following medications are often prescribed:8

  • Naloxone: This medication is used in cases of confirmed or suspected overdose to rapidly reverse the effects of the overdose.
  • Buprenorphine: This medication is a partial opioid antagonist; it is used to reduce dependency on opioids, withdrawal effects, and abuse potential.
  • Suboxone: This medication is a combination of the previous 2 medications and is used to reverse overdose symptoms and prevent or lessen the symptoms of withdrawal.
  • Methadone: This medication is a full opioid antagonist. It blocks the effects of opioids and reduces the cravings for opioids.
  • Naltrexone: This medication is used to reduce opioid cravings and block the effects of opioids.

Other medications may also be used at a Community Care Network provider or facility.

What Does Optum Not Cover?

Health insurance plans, including those accepted by the Optum/VA Community Care Networks, don’t usually cover unproven treatments or aversion therapy for mental health illnesses, including substance use and abuse.7

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Does Optum Include Medicaid and Medicare?

If you have VA health benefits, you can use them with other types of health insurance, including Medicare or Medicaid, when obtaining care through the Optum/VA Community Care Network.9 Be sure to mention all types of health insurance you may hold when asking your VA provider for a referral to community care so that you will be properly billed for services rendered.

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Sources

  1. Optum. (2020). VA Community Care Network.
  2. Department of Veterans Affairs. (2021). General Community Care.
  3. Department of Veterans Affairs. (2019). Veteran Community Care Eligibility.
  4. Department of Veterans Affairs. (2021). Community Care Network.
  5. Department of Veterans Affairs. (2019). Veteran Community Care – Billing and Payments Fact Sheet.
  6. Healthcare.gov. Mental health & substance abuse coverage.
  7. Department of Veterans Affairs. Treatment Programs for Substance Use Problems.
  8. Substance Abuse and Mental Health Services Administration. (2020). MAT Medications, Counseling, and Related Conditions.
  9. Department of Veterans Affairs. (2020). VA health benefits and other health insurance.