FINANCIAL RESPONSIBILITY

QUEST health plans, Medicare, and some commercial health plans provide for full or partial reimbursement of methadone treatment. The rate of reimbursement depends on your specific plan and its coverage.

Treatment charges will be billed to my insurance plan as authorization from my counselor is received. Both medical and counseling services must be authorized for you to use benefits to pay for treatment at Ku Aloha Ola Mau.

1. CHANGE IN PLAN OR STATUS – I am responsible for immediately informing the Ku Aloha Ola Mau counselor of any changes in my insurance plan, for example, ineligibility or change of plan.

2. NON-COVERAGE BY HEALTH PLANS – If for any reason my plan does not pay for medical or other treatment costs, I understand that I am financially responsible for my treatment at the self-pay rates listed below. I will be able to develop a payment plan with Ku Aloha Ola Mau if I so wish.

3. DISENROLLMENT AND / OR FAILURE TO RECEIVE AUTORIZATION – If I have been disenrolled from a plan and have not re-enrolled in another, I understand I am responsible to pay the daily, weekly or monthly rate until I have secured insurance coverage and Ku Aloha Ola Mau has received authorization to provide me with methadone treatment. If there has been duplicate coverage (from myself and the plan), I will be reimbursed by Ku Aloha Ola Mau for that specific amount and time of service.

4. NON-PAYMENT – If I do not meet payment obligations I will be in non-compliance with my treatment plan goal/objectives and Ku Aloha Ola Mau policy. If one payment is missed a $10 late fee will be assessed; if two consecutive payments are missed I will be discharged from the program; if on the methadone program this discharge will follow a 10-day detox.

Methadone Treatment - $575 per month or $133 a week (includes methadone medication, individual and group counseling, doctor's visit, lab work, annual exam and monthly urine drug screen.)

Buprenorphine Treatment - $225 for the first month (includes monthly doctor visit, urine drug test and monthly counseling.)  $90.00 thereafter for doctor visit and onsite urine drug screen.

Substance Abuse Treatment (Non-Medicated Assisted Treatment) -

     Individual Counseling session $60.00 per session

     Group Session - $50.00 per group

     Physician Office Visit - $75.00 per visit (optional)

     Onsite Drug Trest - $15.00 

 

had read, understand, and received a signed copy of the Financial Responsibility form. I was provided with the opportunity to ask questions about sections I did not fully understand. I understand that my signature will remain in effect throughout my current treatment episode at Kū Aloha Ola Mau.