Does Insurance Cover PHP? What to Expect for Coverage and Cost

In the majority of cases, your health insurance covers a partial hospitalization program (PHP).

However, the extent of the coverage can depend on your plan. In this guide, we’ll share everything you need to know about insurance and PHPs, including what’s generally covered, what isn’t, and what to watch out for.

At LAOP, our PHP focuses on offering comprehensive treatment through a combination of individual therapy, group therapy, and psychiatric care to support clients in their recovery journey. And we’ve written this guide alongside our admissions team who deal with insurance every day.

Why Most Health Insurance Plans Are Required to Cover PHP

For most plans, covering PHP is required by law. Under the Affordable Care Act, mental health and substance use treatment is one of ten essential health benefits that Marketplace and most individual and small-group plans must cover. On top of that, the Mental Health Parity and Addiction Equity Act states that mental health care cannot be harder to get access to than comparable medical care.

How Long Will Insurance Pay for PHP?

As a rule of thumb, insurance will generally start off covering somewhere between two weeks and 30 days, then your insurer will likely reassess whether you need to continue receiving treatment — this will happen in coordination with the clinical staff and your PHP provider.

After the initial period, your insurer will likely authorize treatment in short increments. Continued PHP approval is based on medical necessity and whether this level of clinical care is required.

Authorization often comes week by week or even day by day. Some carriers think in units, where a unit equals a day of programming, and a full PHP day usually runs five or six hours.

PHP programs are also designed to be fairly short for reasons that have nothing to do with insurance. PHP generally runs six hours a day in group sessions and one-on-ones, and doing that every day for months on end can lead to fatigue. For many people the right arc is a few weeks of PHP and then a step into intensive outpatient programming (IOP), where the hours drop.

In-Network vs. Out-of-Network PHP Coverage

The relationship between your care provider and insurer often matters more than anything else when it comes to how much you might have to pay out of pocket.

In-network means your plan has a contract with the provider and agreed rates, so your out-of-pocket costs are usually lowest there. Out-of-network means there’s no contract, but that doesn’t automatically put a program out of reach. 

What you’d pay depends on your plan type. PPO plans typically include out-of-network benefits, meaning your plan still pays a share of the cost – often with a higher deductible or coinsurance than in-network, but real coverage all the same. HMO and EPO plans, on the other hand, generally only cover in-network care outside of emergencies.

If you’re on an HMO or EPO plan and your preferred PHP provider is out-of-network, you can explore a single case agreement, where the provider asks your carrier to cover the stay as if it were in-network. 

You’ll need reasons why the out-of-network provider makes the most sense, like an in-network option being across town where the commute is a barrier to showing up every morning, or a clinical or cultural fit the network can’t match, like a therapist who speaks Spanish. (If you’re on a PPO, you usually don’t need one – your out-of-network benefits already apply.)

What Costs Does Insurance Not Cover?

Even if you have great coverage, you may still need to cover some PHP costs, including:

• Travel: Insurance often won’t cover the cost of getting to your PHP every day, though some providers may offer assistance.
• Medication: Prescription costs depend on your insurance plan and any applicable copays.
• Lost income: PHP can take up a large chunk of your day, and if you’re stepping back from work, you may lose income for the period you’re in the PHP.

How to Verify Your Coverage in One Call

If you’re thinking about PHP, that can be a lot to consider, even before it comes to figuring out your insurance. But you don’t have to guess or go it alone. Often, one phone call with your program’s admissions team is all it takes.

If you give the admissions team your insurance details they should be able to run a verification of benefits (VOB) which will confirm whether you’re in-network, out-of-network, and whether prior authorization is required.

The verification of benefits may also be sent to you via post. At first glance, it can look like a bill and worry some people, but it’s just showing a summary of what your insurer has processed and what your plan is handling. It’s not a balance you owe.

If you’d rather ask the questions to your insurer yourself, these are the ones that matter most:

• Is PHP a covered benefit on my plan?
• Are they an in-network or out-of-network provider?
• Do I need prior authorization or a referral to start?
• What’s my deductible, my copay or coinsurance, and my out-of-pocket maximum?
• Are there any limits on the number of days or sessions?

What Happens If You’re Denied or Uninsured

If your insurer denies your request or an extension request, it’s not the end of the road. There’s a process we can follow to try and get approval.

Most carriers run what’s called a peer review, where your clinician talks directly to the carrier’s reviewing physician and discusses the medical necessity for PHP to continue.

If you don’t have insurance or would rather pay for treatment yourself, that’s also an option.

Your Next Step: Get a Straight Answer on Cost

So, does insurance cover PHP? In most cases, yes. But it’s worth fully understanding your plan and its benefits. Often the best way to do this is by speaking to either your insurer or your care provider’s admissions team.

At LAOP, we’re in-network with insurers like Blue Shield of California, TRICARE, TriWest, and Magellan Health. Whether a given program is in-network or out-of-network with your specific plan is the first thing to pin down when it comes to figuring out how much PHP may cost you.

From our Culver City practice, the team runs PHP and IOP for adults, and if you speak to our admissions team, we can verify your benefits and confirm what, if any, costs you may have to pay for out of your own pocket.

To find out what PHP would cost on your specific plan, talk to our admissions team or call 888-449-0852. There’s no obligation, and no surprise costs.

If you’re in crisis or thinking about harming yourself, please don’t wait on an insurance question. Call or text the 988 Suicide & Crisis Lifeline any time, day or night.

Frequently Asked Questions

Does Medicare or Medicaid cover PHP?

Medicare Part B generally covers partial hospitalization in approved hospital outpatient or community mental health settings, paying 80 percent of the approved amount after your Part B deductible and leaving you the other 20 percent. Medicaid covers PHP too, but the details vary by state, so check your specific plan.

How many days of PHP will insurance pay for?

Usually about two weeks to 30 days on the first authorization, then a reassessment. If your team thinks you need more time, they can appeal for it.

Do I need a referral or prior authorization for PHP?

It depends on the plan. PHP is often voluntary and self-referable, but many plans require prior authorization before they’ll cover it. A quick benefits call tells you which camp you’re in.

Is PHP cheaper than inpatient treatment?

Generally yes, because you go home at night instead of staying overnight, which removes the room-and-board cost of a hospital. That’s part of why insurers often favor it when it’s clinically appropriate.

Is the verification of benefits (VOB) a bill?

No. It’s an itemized summary of what your insurer has processed, not a balance due. It can look like a bill, but you don’t owe anything based on it.