What is a Deductible?
A deductible is the amount you pay for health care services before your health insurance begins to pay.

How it Works: If your plan’s deductible is $2,000, you’ll pay 100% of eligible health care expenses until the amount paid totals $2,000. After that, you share the costs with your plan by paying coinsurance.

Why am I being asked to pay my deductible upfront for drug and alcohol treatment services?

The costs of drug and alcohol treatment services will typically exceed your deductible. When that happens, deductibles are collected upfront as a way to ensure the insurance company will pay their portion of the coinsurance.

What is Coinsurance?
Coinsurance is your share of the costs of a health care service. Patient coinsurance responsibility is typically displayed as a percentage; you start paying coinsurance after you’ve paid your plan’s deductible.

How it Works: You’ve paid $2,000 in health care expenses and met your plan’s deductible. Now, instead of paying for all the costs associated with the health care service, your insurance plan shares the cost with you. For example, your plan pays 70% until your Out of Pocket Maximum has been met. The 30% you pay is your coinsurance. The 30% due typically comes in the form of a bill from the service provider at a later date. Patients are required, by their insurance carrier, to pay the coinsurance to the health care provider until the Out of Pocket Maximum has been met.

What is an Out of Pocket Maximum?
An Out of Pocket Maximum is the maximum dollar amount you will pay towards health care services. Dollar amounts paid towards your deductible, coinsurance, and copays count towards your out of pocket maximum. Monthly premiums and any amount paid for health care services that aren’t included in your plan’s benefits do not count towards your out of pocket maximum.

NOTE: Some health insurance plans do not apply deductible amounts towards the out of pocket maximum. This information will be provided to you by Ocean Hills Recovery after a verification of your health insurance benefits has been conducted. You may also verify this information by calling your health insurance.

How does an Out of Pocket Maximum work on a family insurance plan?
Family insurance plans have two out of pocket maximums; individual and family. When the out of pocket maximum has been reached for one person on the plan, that person will be covered at 100% of the allowed amount for that person. When the dollar amount paid towards deductibles, coinsurance, and copays add up to the family out of pocket max, the plan will pay 100% the allowed amount for health care services for each individual on the plan. The patient is no longer responsible for deductibles, copays, and coinsurance once the Out of Pocket Maximum is reached; however monthly premiums must still be paid in order to keep your insurance plan active.
Why am I being asked to pay my out of pocket maximum upfront for drug and alcohol treatment services?
The cost of drug and alcohol treatment services will typically exceed your coinsurance responsibility. When that happens, the amount remaining for your out of pocket maximum is collected up front as a way to ensure the insurance company pays for your health care services while in drug and alcohol treatment.
What if I don’t have the money to pay my Out of Pocket Maximum?
Ocean Hills Recovery recognizes that admitted to drug and alcohol treatment can pose extreme financial stress on the addicted individual and their loved ones. Because our focus is getting the client better, we have two options to help relieve some of that financial stress.

  1. Payment plans. If you are unable to pay your out of pocket maximum up front you may asked to be placed on a payment plan with monthly payments as low as $50/month until the cost of your out of pocket maximum is paid in full.
  2. Sliding Fee Discount Application. Qualified individuals may complete a Sliding Fee Discount Application to be applied towards the Out of Pocket Maximum. This application will not completely negate your financial responsibility to pay the Out of Pocket Maximum but may decrease the amount owed.
I have valid insurance accepted by Ocean Hills Recovery and my Out of Pocket Maximum has been met, why am I still being asked to pay money?
This occurs for one reason: The maximum benefits offered by your health insurance plan will not completely cover the costs of your drug and alcohol treatment. You are being asked to supplement your insurance coverage via a dollar amount. For example, your insurance pays $7,000 for 30 days of residential treatment when 30 days of residential treatment costs $28, 000. You are being asked to pay $18,000 to supplement your insurance.
I received an Explanation of Benefits from my insurance provider, what do I do now?
An explanation of benefits is not a bill. This letter is from your insurance provider explaining the amount paid to the health care provider and for what benefit class code. There is a section on the form that states, “patient responsibility.” This is your coinsurance amount for the health care services you received. This is not a bill and no further action is required from you. You may receive a separate bill from Ocean Hills Recovery, Inc. requesting you pay your coinsurance. Remember, coinsurance is paid to the health care provider and not to the insurance company.
Ocean Hills Recovery is not an In-Network Provider for my insurance carrier, should I expect additional costs?
No. If your health insurance plan covers the cost of drug and alcohol treatment, you will only be required to pay any copays, deductible amounts owed, and to fulfill your Out of Pocket Maximum.
Does Ocean Hills Recovery, Inc. accept Medical, Medcaid, or Medicare as health insurance?
Unfortunately we do not. Treatment facilities accepting state provided insurance plans can be found by contacting SAMHSA either by phone: (877) 726-4727 or via website: www.samhsa.gov