Prominence Health Plan
Prominence Health Plan was formulated in Reno, Nevada, in 1993. It was originally an HMO program (health maintenance organization) that was known as St. Mary’s Health Plans. In 2014, the company was acquired by a subsidiary of Universal Health Services, Inc. (UHS) and renamed Prominence Health Plan. UHS is one of the nation’s largest healthcare management companies with over 65,000 employees.
Prominence Health Plan offers HMO services, preferred provider organization health plans (PPOs), and point of service health plans as well as a Medicare Advantage program (an additional insurance add-on for individuals who have Medicare).
HMO plans allow access to facilities and physicians within a specific network. This network of providers has agreed to offer lower rates for members of the plan. Coverage under an HMO plan is only ensured if you see a provider within the network. Seeing a provider outside the network will result in specifically higher out-of-pocket costs.
PPO plans also feature a network of providers for the individual to use but have more flexibility regarding seeing someone outside of the network. Point of service plans are basically PPO plans that allow the client to choose either an HMO provider or a PPO provider each time they need treatment for a specific issue. Their premiums are significantly increased.
A listing of the types of plans provided by Prominence Health Plan for individuals and families in Nevada can be found here. Many of these plans are HMO plans that are either paid for by the individual, or the cost of the policy is partially subsidized. Subsidized plans are typically at least partially financed by some other source, such as an employer (usually at least 50 percent of the cost is covered), and an individual picks up the balance of the premium.
Substance Use Disorder Coverage
Out-of-pocket costs vary for substance abuse treatment, depending on the specific plan. According to its website, Prominence Health Plan suggests that individuals receive prior certification for substance use disorder treatment, including inpatient care, medical detox, therapy, and medications. Many of the HMO plans require referral from a physician before the specific treatment is covered. Physicians can also assist in the process of determining the medical necessity for very costly treatments, such as inpatient or residential treatment and withdrawal management (medical detox).
For instance, as of 2017, the Bronze 10 Premier plan in Nevada requires an individual to cover a $4,000 copay for inpatient or residential treatment, including withdrawal management or medical detox treatment. The Gold 2 Premier plan has a much lower $500 copay for this type of treatment. Obviously, the premiums for the plans differ substantially, with significantly higher costs associated with Gold plan premiums. Plans also vary depending on geographical area, as different areas offer different plans with different copays, making the situation rather complicated.
Policyholders with Prominence Health Plan are strongly encouraged to contact their appropriate customer service representative regarding the exact type of coverage that their plan allows. As a general rule, it is always recommended that any individual contemplating treatment for a substance abuse issue seeks a referral from a physician for treatment, as physician referrals help to reduce complications associated with coverage, issues with copays, acceptance and denial of claims, and so forth. Many insurance providers have a requirement of medical necessity for certain treatments to be covered, and physician referrals usually fulfill this requirement.