Medicaid Insurance & Coverage For Alcohol And Drug Rehab

Last Updated: June 10, 2020

Medicaid insurance covers 1 out of every 5 low-income Americans. This means that many people are dependent upon the program for accessing Medicaid drug rehab coverage. It is imperative that all people insured through the program understand what their policy covers and how to use Medicaid for substance abuse rehab.

Does Medicaid Cover Drug Rehab?

Medicaid coverage does, in fact, extend to substance abuse rehab. However, precisely what is covered can vary between states. This can be problematic as nearly 12% of adults insured under Medicaid have a substance use disorder. The result is that some of these individuals will have access to comprehensive treatment, while others living elsewhere will have their options severely restricted in comparison.

However, anyone with Medicaid will have access to some form of rehab coverage. Due to the Affordable Care Act, Medicaid health insurance covers substance abuse.

Who Is Eligible For Medicaid?

Not everyone with a substance use disorder will qualify for Medicaid coverage. In all 50 states and Washington D.C., this coverage is available to the following populations:

  • Low-income people, with the threshold for “low-income” being determined by the state
  • Families and children, depending on income
  • Pregnant women
  • The elderly
  • People with qualifying disabilities

Users can find out if they are eligible by either going to their state’s Medicaid website or by filling out an application with the Health Insurance Marketplace. For those who qualify, coverage starts immediately, making Medicaid coverage for drug rehab a good option for uninsured individuals needing help quickly.

Criteria For Drug Rehab Coverage

For substance use disorder to be covered, the patient needs to have a diagnosis from a medical professional who works with Medicaid. They need to provide a diagnosis and referral, stating that the patient needs treatment. Even with this, Medicaid drug rehab coverage may not be as complete as a person requires.

States have been encouraged to offer better coverage for drug addiction, alcohol addiction, and behavior disorders in general. Slowly, change is being seen. However, for some, it will come too late.

Substance Abuse Services Covered Under Medicaid Insurance

Given that policies vary by region, Medicaid coverage of medications for the treatment of opioid use disorder, rehabs, and other forms of treatment will vary. Some services that are commonly covered include:

Anyone in need of Medicaid detox coverage or other services should verify what is available to them in their state

prescription pills on the laptop

Does Medicaid Cover Opioid Treatment?

Yes, Medicaid does cover opioid treatment, from safely detoxing from these substances to using medications to prevent cravings and relapse. As with all Medicaid coverage, what is covered may vary from state to state, with restrictions preventing truly comprehensive access. For those with complete coverage, medications that might be prescribed include:

  • Buprenorphine sublingual, implant, and injectable
  • Buprenorphine and naloxone combination oral and sublingual
  • Naltrexone oral and injectable

If a user feels strongly that they will need medication to stay clean, they need to check to see what the limits on coverage are.

drunk man lay in the bar

Does Medicaid Cover Alcohol Treatment?

Medicaid mental health coverage includes alcohol rehabilitation. As with opioids, this covers detox, rehabilitation, and maintenance. What restrictions apply to this coverage will vary between states, and users should always verify coverage before assuming they will have access to a specific treatment or medication. Medicines that might be covered for alcohol use disorder include:

  • Acamprosate calcium oral
  • Disulfiram oral
  • Naltrexone oral and injectable

What Is Not Covered?

Medicaid drug rehab coverage certainly has its limits, and there are some things that simply are not covered. Some items that will not be paid for by the program include:

  • Any treatment not backed up by the diagnosis of a doctor
  • Any treatment offered by facilities not affiliated with Medicaid
  • Any medications that are not on the approved prescription list
  • Alternative therapies, such as art and equine therapy
  • Additional services, such as massages and saunas
  • Inpatient rehab stays that exceed the maximum number of days covered
  • Outpatient sessions that exceed the maximum number of sessions covered

Medicaid Cost Sharing

States have significant control over Medicaid. One of the ways they can impact it is through the establishment of out of pocket spending for those who are insured—something called cost-sharing. These means charging premiums, setting deductibles, and requiring things like copayments and coinsurance. While there is a cap on out of pocket costs, the fact that they exist in some states means Medicaid coverage for inpatient rehab and other treatments can get expensive.

two money boxes

In all states, certain populations that are deemed vulnerable are exempt from cost-sharing. These include:

  • Children under age 18 (with certain restrictions)
  • Individuals living in an institution who are required to contribute the majority of their income toward the cost of their care
  • Individuals in hospice care
  • American Indians and Alaska Natives who have ever received a service from the Indian Health Service, tribal health programs, or under contract health services referral
  • Women who are enrolled in Medicaid under the Breast and Cervical Cancer Treatment Program are exempted from alternative out of pocket costs only

Some services are also exempt from cost-sharing. The only one that relates to Medicaid coverage for substance abuse treatment is emergency services. Users who are overdosing or going through dangerous withdrawals can seek emergency care without having to pay out of pocket.

An example of out-of-pocket costs is as follows:

Services and Supplies 100% FPL 101-150% FPL More Than 150% FPL
Institutional Care (inpatient hospital care, rehab care, etc.) $75 10% of the cost the agency pays for the entire state 20% of cost the agency pays for the entire state
Non-Institutional Care (physician visits, physical therapy, etc.) $4.00 10% of costs the agency pays 20% of costs the agency pays
Non-emergency use of the ER $8.00 $8.00 No limit
*within 5% aggregate limit
Preferred drugs
Non-preferred drugs
20% of cost the agency pays

Users should keep in mind that the exact costs will vary by state and depending on if someone qualifies as being part of a vulnerable population. 

How To Apply For Medicaid

Anyone eligible can apply for Medicaid insurance coverage at any time of year; there is no open enrollment period. This can be done online through the state’s website or the federal health insurance marketplace.

Certain documentation will be needed to support the application. This can include:

  • Birth certificate
  • Driver’s license
  • Pay stubs
  • Tax returns
  • Bank statements
  • Proof of address
  • Medical records

Can One Apply For Both Medicare And Medicaid?

It is possible to apply for both Medicare and Medicaid. Some people fall into dual eligibility, meaning they qualify for both programs. For example, those over the age of 65 who have low income will qualify for both, as will many people with disabilities. There is no law preventing people from being enrolled in both and using whichever program best meets their needs at a given time.

Drug Rehab Coverage Can Be Affordable

If someone has Medicaid coverage, they likely can have their drug rehab covered in a state-funded rehabilitation center; a private drug rehab is rarely covered. All they need to do is verify their coverage and its limits, then enroll in an approved program.

Page Sources

  1. Substance Use Disorders.
  2. Who is eligible for Medicaid? 2017.
  3. Medicaid Coverage of Medication-Assisted Treatment for Alcohol and Opioid Use Disorders and of Medication for the Reversal of Opioid Overdose. Substance Abuse and Mental Health Services Administration. 2018.
  4. Out-of-Pocket Cost Exemptions.

Published on: October 2nd, 2019

Updated on: June 10th, 2020


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