Optum Insurance

New Directions for Women has partnered with Optum health insurance for many years and works carefully to meet the needs of the women in our treatment program by adhering to the regulations set by Optum. The goal of Optum is to connect the brightest people, places, and ideas across the healthcare ecosystem to create better life-long care for everybody.

New Directions for Women holds a license that allows us to treat women with a substance use disorder (SUD) in the state of California. We are also certified by the American Society of Addiction Medicine (ASAM) and accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). We are striving to become the most knowledgeable and educated on substance use disorder for the individual women that we serve at our facility. All guidelines that we use follow ASAM standards.

What Is Optum?

In Southern California, Optum (formerly known as HealthCare Partners) provides quality medical care through two delivery models:

1. Staff Model: In the staff model, Optum employs primary care physicians and specialists.
2. Independent Physician Association (IPA) Model: Optum contracts with independent primary care physicians and specialists.

Optum is the management services organization and it manages the departmental systems of the staff model and provides the full array of central support services to the IPA network.

Optum Staff Model

The Optum medical group has been rated as one of the best in California. The group is composed of:

• More than 65 medical clinics
• More than 600 primary care physicians and specialists

The group provides health care services to both HMO (Health Maintenance Organization) enrollees and fee-for-service clients and has contracts with most major HMOs and PPOs (Preferred Provider Organization) serving the Greater Los Angeles area. In addition, Optum is one of the biggest single providers of prepaid health care for seniors in California.

The Optum service area includes:

• Los Angeles
• Pasadena/the San Gabriel Valley
• South Bay
• Long Beach
• San Fernando and Santa Clarita Valleys
• Orange County

IPA Model 

In the IPA model, physicians in the community who are associated with Optum and the communities they serve have access to a larger selection of physicians. The IPAs are made up of more than 1,600 contracted primary care physicians. More than 4,000 specialists are also contracted with Optum. These specialists see clients referred by both IPA and staff model primary care physicians. The IPA service area covers and extends the staff model clinics.

What’s an HMO?

An HMO is meant to lower costs and keep them predictable. In an HMO, you have one doctor to coordinate your care which helps make it simple to use. Along with that, it offers: 

• Monthly premiums, copays, and deductibles that are usually lower than other types of plans.
• Access to certain doctors and hospitals, known as your provider network. This helps you control how much you pay for health care.
• A primary care physician (PCP) who you visit for routine physicals, check-ups, colds, and flu. When you first sign up, you will choose or be assigned a PCP. The PCP will refer you to a specialist for more serious issues.

What’s a PPO?

PPO (Preferred Provider Organization) plans give you more flexibility when choosing a doctor or hospital. They also have a network of providers but have fewer restrictions on seeing a non-network physician. Besides, your PPO will pay if you see a non-network provider, but it might be at a lower rate. Some important details about PPOs:

• You can go to the doctor or specialist you want without having to see a PCP first.
• You can go to a doctor or hospital outside the network and be covered. However, your benefits will be better if you stay in the PPO network.
• PPO premiums tend to be higher and there is usually a deductible.

What is Fee-for-Service (FFS)?

The most traditional payment model for healthcare is fee-for-service. In this model, the healthcare providers are repaid based on the number of services they provide or the procedures they conduct. The insurance company is billed for every test, procedure, and treatment provided whenever the person visits a doctor.

The FFS plan is the most expensive, but it allows complete independence for the client. They are free to choose their physicians and hospitals. This plan requires high out-of-pocket expenses because clients may have to pay their medical fees upfront and be reimbursed by the company.

Prepaid Plans

Prepaid, or managed, care plans usually arrange to provide medical services for plan members in exchange for subscription fees paid to the plan by the sponsor (i.e. the member’s employer). Services are provided by physicians and hospitals that also have a contract with the sponsor. 

Therefore, managed care plan supervisors act as middlemen by contracting with both the providers and the members to deliver medical services. In this way, subscribers (you) get the benefit of reduced health care costs, and healthcare providers get the benefit of a guaranteed group of clients.

Are You Covered for Care?

Since 2014, most individual and small group medical insurance plans (including those sold in the Healthcare Marketplace) are required to cover mental health and substance use disorder (SUD) services. The plans must have coverage of essential health benefits which include mental health and SUD services. Another is rehabilitative services.

Additionally, these plans are required to follow the mental health and substance use parity requirements. Coverage for mental health and SUD services can’t have more restrictions than coverage for medical and surgical services. Generally speaking, for people in large employer plans, if mental health and SUD services are offered, they are bound to the parity protections. And as of 2014, most small employer and individual plans, mental health, and SUD services must meet the MHPAEA (Mental Health Parity and Addiction Equity Act) requirements.

Focusing on Women at New Directions

At New Directions for Women, we will build a program specifically for you. We believe that every woman is unique and needs care that addresses her needs. New Directions for Women offers a continuum of care that helps treat each woman in our program, at the level she needs. Levels of Care offered at New Directions for women are:   

Detox

Before you begin formal treatment, you need to go through detoxification to rid your body of the toxins you’ve been using. In detox, you will go through withdrawal symptoms. You will need time to adjust mentally and physically from suddenly stopping your drug use.

Withdrawal symptoms during detox can be very mild but sometimes very serious, even life-threatening. This is why it’s better to be in a place with 24-hour monitoring in case of an emergency. When appropriate, you may be prescribed medication to help ease the withdrawal symptoms.