Does Oscar Health Cover Rehab? What Your Plan Pays For

Oscar Health is a technology-focused health insurance company founded in 2012 with a mission to make healthcare simple and transparent. Unlike traditional carriers that have been around for decades, Oscar was built from the ground up as a tech-first insurer, emphasizing mobile apps, 24/7 concierge care teams, and streamlined member experiences. Oscar covers approximately 1.6 million members across 19 states and DC, primarily through ACA marketplace plans and Medicare Advantage.

What Does Oscar Health Cover for Rehab?

As an ACA-compliant carrier, Oscar Health covers the full continuum of substance use disorder treatment when medically necessary:

Covered Services

Medical Detoxification — Medically supervised withdrawal in hospital or freestanding detox facilities. Covered at 60-80% after deductible for in-network facilities. Duration based on medical necessity, typically 3-14 days.

Inpatient/Residential Treatment — 24/7 residential programs providing comprehensive addiction treatment. Oscar covers 60-80% after deductible for in-network facilities. Initial authorization typically 7-14 days with concurrent review for continued stay.

Partial Hospitalization Program (PHP) — Intensive day treatment 6+ hours daily. Covered at 70-90% after deductible.

Intensive Outpatient Program (IOP) — Structured outpatient treatment 9-15 hours weekly. Covered at 70-90% after deductible.

Outpatient Therapy — Individual and group counseling. Covered at 80-90% after deductible, with typical copays of $30-$60 per session.

Telemedicine for Follow-Up Care — Oscar integrates telemedicine, often at $0 copay, which can be used for therapy sessions and MAT follow-up appointments.

Medication-Assisted Treatment (MAT) — All FDA-approved medications:

• Buprenorphine products (Suboxone, generic buprenorphine/naloxone, Sublocade injection)
• Methadone through certified opioid treatment programs (OTPs)
• Naltrexone (Vivitrol injection, ReVia tablets)
• Acamprosate (Campral)
• Disulfiram (Antabuse)

Coverage: 80-90% after deductible, depending on drug tier. Oscar emphasizes generic medications when available.

Oscar Plan Types and Rehab Coverage

Oscar EPO (Most Common)

Best for: Tech-savvy members wanting streamlined experience with regional network

Network: Regional network, must stay in-network Out-of-network: Not covered except emergencies Referrals: Not required Typical coverage: 60-80% in-network after deductible Average out-of-pocket for 30-day inpatient: $5,000-$18,000

Oscar EPO plans are the most common, offering no referral requirements but requiring in-network care.

Oscar HMO

Best for: Lower premiums with primary care coordination

Network: Regional network Out-of-network: Not covered except emergencies Referrals: Required from PCP Typical coverage: 70-85% in-network after deductible Average out-of-pocket for 30-day inpatient: $4,500-$16,000

Oscar HMO plans have the lowest premiums but require PCP referrals.

Oscar+Cigna (Network Partnership)

Best for: Members wanting Oscar’s experience with Cigna’s broad network

Network: Access to Cigna’s 1,900+ addiction treatment facilities nationwide Out-of-network: Varies by plan design Referrals: Typically not required Typical coverage: 60-80% in-network after deductible Average out-of-pocket for 30-day inpatient: $6,000-$20,000

Oscar+Cigna combines Oscar’s tech platform with Cigna’s extensive provider network, offering the best of both.

Oscar PPO (Limited Availability)

Best for: Maximum flexibility (only available in select markets)

Network: Broader than EPO Out-of-network: Covered at reduced rate (50-60%) Referrals: Not required Typical coverage: 60-80% in-network, 40-60% out-of-network after deductible Average out-of-pocket for 30-day inpatient: $6,000-$20,000

Oscar PPO is only available in limited markets and has higher premiums.

Oscar’s Tech-Forward Approach to Addiction Treatment

Oscar differentiates itself through technology and member experience:

Oscar App

Central hub for everything:

• Find in-network addiction treatment facilities
• Verify your benefits and coverage in real-time
• Get cost estimates before treatment
• Track preauthorization status
• Message your Care Team 24/7
• Access virtual care for therapy and MAT follow-up
• View claims and EOBs

Real-time cost estimates: Oscar’s app shows estimated out-of-pocket costs for inpatient treatment before you commit, reducing surprise billing.

Oscar Care Team

24/7 concierge support:

• Text or call Oscar’s Care Team anytime (no phone trees)
• Care guides help you find addiction treatment facilities
• Assistance with preauthorization process
• Answers to coverage questions
• Care coordination during treatment

Dedicated support: Unlike traditional insurers where you navigate automated systems, Oscar provides direct access to real people.

Virtual Care Integration

$0 copay telemedicine:

• Many Oscar plans include $0 copay virtual primary care
• Can be used for therapy sessions (individual counseling)
• MAT follow-up appointments via telemedicine
• Reduces barriers to ongoing care after residential treatment

Preauthorization Requirements

Oscar requires preauthorization for all inpatient and residential substance abuse treatment:

Before Treatment

1. Clinical assessment — Intake evaluation at treatment facility
2. Facility submits authorization — Utilization review team sends preauthorization to Oscar’s behavioral health team
3. Oscar reviews — Clinicians assess medical necessity using ASAM criteria
4. Authorization decision — Typically 24-48 hours

Oscar advantage: Track authorization status in real-time through the Oscar app rather than calling repeatedly.

Medical Necessity Criteria

Oscar uses ASAM (American Society of Addiction Medicine) criteria:

• Acute intoxication/withdrawal potential
• Biomedical conditions and complications
• Emotional, behavioral, cognitive conditions
• Readiness to change
• Relapse/continued use potential
• Recovery environment

During Treatment

Concurrent review: Oscar conducts ongoing reviews every 3-7 days. The facility provides clinical updates showing progress and continued medical necessity.

App-based tracking: Members can see authorization status updates in the Oscar app.

Typical Out-of-Pocket Costs with Oscar

Your costs depend on your specific plan. Here’s a typical example:

Example: Oscar EPO (Silver Plan)

Plan details:

• Deductible: $1,500 (individual)
• Coinsurance: 80/20 (Oscar pays 80%, you pay 20%)
• Out-of-pocket maximum: $8,200 (individual)

30-day inpatient program (in-network):

• Facility negotiated rate: $32,000
• You pay deductible: $1,500
• Remaining balance: $30,500
• You pay 20%: $6,100
• Total you pay: $7,600

Medical detox (7 days, in-network):

• Facility cost: $4,500
• You pay: $1,500 (deductible) + 20% of $3,000 ($600) = $2,100

MAT (monthly costs):

• Generic buprenorphine: $20-$50 copay
• Brand Suboxone: $75-$125 copay
• Vivitrol injection: $75-$200 copay

Cost transparency: Oscar’s app shows estimated costs before treatment, so you know what to expect.

Cost Comparison by Plan Type

Verifying Your Oscar Coverage

Oscar makes it easy to verify coverage through multiple channels:

Use the Oscar App (Easiest Method)

Oscar mobile app:

1. Log in with your member credentials
2. Search for treatment facility using provider search
3. View your benefits (deductible, out-of-pocket max, coinsurance)
4. Get cost estimate for inpatient treatment
5. Message Care Team with questions

Call or Text Oscar Care Team

Oscar Care Team: 1-855-672-2788 (or text via app)

Questions to ask:

• Is [facility name] in-network for my plan?
• What is my deductible, and how much have I met?
• What is my coinsurance for inpatient behavioral health?
• What is my out-of-pocket maximum?
• How does preauthorization work?
• What will my estimated out-of-pocket cost be for 30-day treatment?
• Does my plan cover MAT medications?

Oscar’s Care Team provides direct answers without phone trees.

Have the Facility Verify Benefits

Treatment facilities can:

• Verify your Oscar benefits
• Get cost estimates
• Initiate preauthorization
• Explain payment options

Oscar’s Behavioral Health Network

Oscar’s network is smaller than major carriers but focuses on high-value providers:

Network size: Approximately 800+ addiction treatment facilities (standalone Oscar) +Cigna network: 1,900+ facilities (via Cigna partnership)

Types of facilities:

• Hospital-based detox and inpatient programs
• Residential treatment centers
• Intensive outpatient programs (IOP)
• Partial hospitalization programs (PHP)
• Medication-assisted treatment providers
• Opioid treatment programs (methadone)

Geographic coverage:

• Network varies significantly by state
• Strongest in major metropolitan areas (NYC, LA, SF, Miami, Dallas)
• Rural areas may have limited options
• +Cigna plans offer significantly broader coverage

Network philosophy:

• Emphasis on high-value providers
• Quality over quantity approach
• Curated networks based on outcomes data

What Makes Oscar Different

Consumer-First Experience

Oscar was built to reimagine health insurance:

• Mobile-first design (everything through app)
• 24/7 human support (no automated phone systems)
• Transparent pricing (cost estimates before care)
• Simple, jargon-free communication

Technology Integration

• Real-time benefits verification
• Authorization tracking
• Telemedicine integrated at $0 copay
• Digital care coordination

Smaller, Curated Networks

Advantage: Focus on high-quality, cost-effective providers Disadvantage: Fewer choices than carriers like UnitedHealthcare or Cigna

Limitations and Considerations

Network Size

Oscar’s standalone networks are smaller than major carriers:

• Fewer addiction treatment facilities
• May not include high-end specialized programs
• Some regions have limited options
• +Cigna partnership addresses this in some markets

Geographic Availability

Oscar is only available in 19 states + DC, primarily in major metropolitan areas.

Newer Company

Founded in 2012, Oscar has less track record than carriers operating for decades. Some providers may be less familiar with Oscar’s processes.

Plan Availability

Oscar is primarily available through:

• ACA marketplace (individual/family plans)
• Medicare Advantage (select states)
• Small group employer plans

Large employer plans are less common.

What If Oscar Denies Coverage?

You have appeal rights under federal law:

Internal Appeals

1. File appeal within 180 days of denial
2. Submit clinical documentation supporting medical necessity
3. Contact Care Team for guidance through appeal process
4. Timeline: Oscar must respond within 30 days (72 hours for urgent)

External Review

If internal appeal denied:

1. Request external review by independent organization
2. Timeline: 60 days for standard, 72 hours for urgent
3. Binding decision on Oscar

State Insurance Department

File complaints with your state insurance department if you believe Oscar violated mental health parity laws.

Don’t Have Oscar (or Any Insurance)?

If you’re currently uninsured, obtaining coverage through the ACA marketplace is often the most cost-effective path to treatment. Oscar is available in 19 states + DC and may be a good option if you value:

• Tech-forward, app-based experience
• 24/7 concierge Care Team support
• Transparent pricing and cost estimates
• Integrated telemedicine

If you need broader provider networks, consider carriers like UnitedHealthcare, Cigna, or Blue Cross Blue Shield during open enrollment.

A licensed insurance specialist can help you:

• Compare Oscar with other carriers in your state
• Understand network differences
• Navigate subsidies and cost-sharing reductions
• Determine which plan best fits your needs

Sources

• Oscar Health. “Behavioral Health Benefits.” Member Resources. 2026.
• Oscar Health. “How Oscar Works.” Company Information. 2026.
• Healthcare.gov. “Mental Health and Substance Use Disorder Coverage.” 2026.
• Centers for Medicare & Medicaid Services. “Mental Health Parity and Addiction Equity Act.” 2024.