Under the Patient Protection and Affordable Care Act (PPACA) of 2010, otherwise known as the Affordable Care Act (ACA), or “Obamacare,” all insurance providers in the Health Insurance Marketplace are required to provide coverage for basic elements of addiction treatment.
This includes Medicaid and Medicare. Medicare and Medicaid offer plans with low or non-existent co-pays that cover a range of substance abuse and addiction treatments, including rehab.
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What is Medicaid and who qualifies?
Medicaid is a public program that provides insurance coverage for individuals and families who might not otherwise be able to pay premiums associated with private insurance coverage.
To be considered eligible for Medicaid, applicants must be one, or more, of the following:
- Over 65 years old
- Under 19 years old
- A parent
- Within a specified income bracket*
People can only apply for Medicaid based on income alone if their state has expanded its Medicaid coverage.
What is Medicare and who qualifies?
Medicare is a public program that provides insurance coverage to people over the age of 65 or to those with disabilities.
People often seek the assistance of Medicaid because they often have medical expenses that are much higher than the average person.
Can One apply for both Medicaid and Medicare?
If one is 65 or older, or have a disability, one may be eligible to apply for both Medicare and Medicaid.
Can One apply for Medicaid or Medicare if One already has private insurance coverage that doesn’t cover addiction treatment?
A person who already has private health insurance can apply for Medicaid assistance if:
- The individual demonstrates financial need
- Proves one is unable to pay current premiums
What Drug and Alcohol Addiction Treatment Options do Medicaid and Medicare Cover?
Because Medicaid and Medicare are not their own health care providers but are instead each made up of a network of approved professional practices, different plans cover different treatment methods.
How Can Medicaid Help Pay for Addiction Treatment?
In most states, Medicaid recipients do not have co-payments for addiction treatment services.
For the states that do require co-payments, there is an out-of-pocket limit that applies to Medicaid recipients.
Some of the addiction treatment methods Medicaid covers include:
- Inpatient rehabilitation
- Long-term residential treatment
Behavioral therapies such as:
- Individual therapy
- Group counseling
- Family behavior therapy
- Cognitive-behavioral therapy
- Other therapy methods
Medications* used to treat withdrawal symptoms and help those in recovery to stay sober, such as:
- Methadone, Buprenorphine (with or without Naloxone), and Naltrexone to treat opioid use disorders
- Acamprosate, Disulfiram, and Naltrexone to treat Alcohol use disorders
Some drugs require special permission or proof that the person is already enrolled in a treatment program in order to qualify for coverage.
How Can One Use Medicare to Pay for Drug and Alcohol Addiction Treatment?
Medicare has four different parts, all of which help to cover different types of costs for alcohol and drug addiction treatment.
Parts A and B are part of “Original Medicare,” whereas Part C, known as “Medicare Advantage,” can serve as an upgraded version of Parts A and B, and part D is an optional addition for those who want to increase the types of costs covered by their insurance.
Part A— Inpatient hospital visits
Medicare Part A, or can help those suffering from addiction by
- up to 60 days in inpatient rehab*
- medications received in rehab
Medicare will only cover a total of 190 inpatient visits of any kind in someone’s lifetime.
Part B— Office visits and other outpatient medical services
Medicare Part B can help cover these drug and alcohol treatment costs:
- Outpatient rehab
- Therapy/ counseling
- Medications administered by clinics
- Medications received during an intervention
- Treatment and medication for co-occurring disorders, like depression.
Part C— Additional coverage through approved private insurers
Medicare Part C is optional for Medicare subscribers. As a standard, Part C is required to cover at least what’s covered by Part A and Part B, but can often provide additional benefits, such as:
- A wider range of provider options, should the person opt for a plant that includes out-of-network care
- Lower medication costs via prescription drug plans
Part D—Prescription drug coverage
Part D is also optional. Medicare Part D can help lower the costs of medications used to treat addiction.
Do All Rehab Centers Accept Medicaid and Medicare?
Unfortunately, not every facility accepts Medicaid and/or Medicare; however, all state-funded rehabilitation facilities do. To find out more information about state-funded rehab centers, visit SAMSHA.gov.
- Substance Abuse and Mental Health Services Administration (US); Office of the Surgeon General (US). Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health. Washington (DC): US Department of Health and Human Services; 2016. CHAPTER 6, HEALTH CARE SYSTEMS AND SUBSTANCE USE DISORDERS. https://www.ncbi.nlm.nih.gov/books/NBK424848/.
- DEPARTMENT OF HEALTH AND HUMAN SERVICES. Medicare Coverage of Substance Abuse Services. 2016. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1604.pdf.
- MEDICAID MANAGED CARE INFORMATION RESOURCE CENTER. Coverage and Delivery of Adult Substance Abuse Services in Medicaid Managed Care. 2014. https://www.medicaid.gov/medicaid/benefits/downloads/cms-adult-substance-abuse-services-coverage.pdf.