What You Need to Know About Medicaid Coverage for Drug Rehab
For those suffering from a substance use disorder (SUD), there may be barriers to getting treatment. These include an inability to afford payment, having no health insurance, and other circumstances. Medicaid is designed for low-income individuals and households, so if you are eligible for Medicaid and have an SUD, there’s a good chance Medicaid will cover a large portion of your rehab treatment. However, things aren’t so straightforward. There are other factors to consider, such as your state, whether Medicaid has expanded in your city, and whether the facility you choose accepts Medicaid. Here is a more in-depth look at Medicaid and drug rehab centers.
What Kinds of Drug Rehabs Are Available?
If you have an SUD, entering a drug rehabilitation program can be a lifesaver. Several factors will determine the best rehab center for your needs, though, such as the severity of your addiction, how long you have taken drugs, or if there are any co-occurring mental health issues. Here are the main types of rehab centers.
Inpatient Rehabilitation Centers
Inpatient rehab facilities offer a structured environment with round-the-clock care. These programs are typically designed for individuals with severe drug addictions. Clients entering an inpatient rehab center stay at the center for the duration of their treatment. This stay can be a few weeks or even a few months.
Long-Term Residential Programs
Some individuals may relapse within days after completing an inpatient rehab program. For clients who have trouble staying clean or who have chronic substance abuse issues, there are long-term residential programs. These programs can last six months or longer. They offer clients skills to deal with their SUD for the rest of their lives.
Outpatient Rehabilitation Programs
For individuals suffering from a mild addiction, outpatient rehab programs are more suitable. These allow clients to attend therapy sessions but still live at home. They can attend work or school, but they must fulfill the program requirements for some hours during the day.
Intensive Outpatient Programs (IOP)
Some individuals may not need to reside in a facility but need a program that is more intense than outpatient rehab. For these clients, there are intensive outpatient programs. These are similar in structure to outpatient rehab programs, but they require clients to attend therapy sessions for several hours daily.
Partial Hospitalization Programs (PHP)
Partial hospitalization programs are similar to intensive outpatient programs. As with IOPs, clients can return home daily after their therapy sessions. PHP programs offer medical monitoring, however. While PHPs are an in-between step between inpatient and outpatient rehab programs, IOPs are designed to cater to the final steps of one’s recovery.
Dual-Diagnosis Treatment Centers
Some individuals suffer from mental disorders — such as schizophrenia, bipolar disorder, or anxiety — along with SUDs. These clients need customized treatment plans that will address both disorders simultaneously.
Holistic Rehabilitation Centers
Holistic rehab centers offer alternate approaches to standard treatments. These centers use a holistic approach, offering a comprehensive treatment designed to heal the body, mind, and spirit. Therapy offered at a holistic rehab center includes acupuncture, yoga, art therapy, adventure therapy, and meditation.
What Is Medicaid, and What Does It Cover?
Established in 1965 along with Medicare, Medicaid offers healthcare coverage to low-income families and individuals. At the federal level, healthcare services are provided by Medicare & Medicaid Services (CMS). The organization then partners with individual states to provide healthcare. Medicaid eligibility varies by state, and several factors are used to determine eligibility. These include income, disability status, and the size of your household.
Here are some features of Medicaid.
Primary Care Services
Medicaid provides coverage for preventive health care, such as visits to your primary care doctor, vaccinations, mammogram screenings, annual gynecological checkups, and outpatient care.
Hospital Services
Medicaid also covers inpatient hospital care, such as medically required treatments, surgeries, and hospital stays.
Prescription Drugs
Individuals with full Medicaid have coverage for their prescription medications though it may be the generic version of the drug rather than the brand name. This part of Medicaid is called Part D. In order to get prescription drugs, you must join either a Medicare Prescription Drug Plan (PDP) or a Medicare Advantage Plan.
Laboratory and Diagnostic Services
Medicaid has limited lab and diagnostic services, so it’s important to find out with the Medicaid services in your state. If specific diagnostic services are necessary for the treatment of a medical condition, Medicaid typically covers them. On the other hand, if Medicaid deems that the lab tests are not medically necessary, coverage will be denied.
Maternity and Newborn Care
Medicaid provides coverage for the entirety of a woman’s maternity. This includes prenatal care, childbirth, and postpartum care. After the child is born, healthcare services are provided for the newborn baby as well.
Long-Term Care Services
Medicaid provides long-term care services for the elderly. These services include assisted living facilities and nursing home care services.
Dental and Vision Care
Medicaid coverage for dental and vision care tends to vary from state to state. Preventive care for dental services, such as twice-a-year checkups, are typically covered. However, procedures such as teeth whitening or braces may not be covered.
Do Drug Rehabs Accept Medicaid?
Yes, there are many drug rehab centers that accept Medicaid. However, it’s important to check with the facility first, as not all take this form of payment. Here are some important considerations.
Coverage Varies
Medicaid usually covers basic treatment services like detoxification, inpatient rehab, and outpatient counseling. However, not all services are covered, and coverage depends on the individual’s eligibility status. Moreover, the rules for treatment change every year. Still, Medicaid is the largest payer for the treatment of U.S. residents with mental and substance use disorders.
Medicaid Coverage Varies By State
Although Medicaid is a federal program, each state is flexible in designing Medicaid programs in the way that it chooses. For this reason, Medicaid coverage varies, with some states offering more coverage than others.
Medicaid Expansion
Under the Affordable Care Act (ACA), Medicaid has expanded and increased access to treatment for those with SUDs. However, this does not apply everywhere, so you must check to see if Medicaid services have been expanded in your state.
Verification and Preauthorization Steps
In order for drug rehab services to cover Medicaid clients, clients must verify that they are covered by Medicaid and go through preauthorization and verification steps. This can differ from facility to facility and state to state.
Out-of-Pocket Costs
While Medicaid may cover some of the treatments offered in drug rehab facilities, not all are covered. Specific medications used or amenities offered at the facility may fall into this category. In that case, clients must pay for these services themselves. These out-of-pocket costs differ from facility to facility. There may be a deductible for the first 60 days, and then a copayment for every additional day, for example.
What Is the Mental Health Parity and Addiction Equity Act?
Enacted in 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA) prevents health insurance providers from providing fewer benefits to people with a mental or substance use disorder compared to those receiving surgical or medical benefits for other reasons.
In addition, providers cannot impose limits to the frequency of treatment. They also can’t impose non-quantitative treatment limitations (NQTLs), such as limitations to reimbursement rates. Nor can they apply limits in a discriminatory manner.
The goal of the MHPAEA is to end discrimination toward people with mental disorders or SUDs. HHS Secretary Xavier Becerra stated, “HHS believes all Americans should have access to mental health and substance use disorder treatment, whenever and however they need it.”
Although MHPAEA is designed to level the playing field for people suffering mental health or substance use disorders, it cannot mandate insurance coverage. In addition, the Equity Act does not apply to all insurance plans.
Who Is Eligible for Medicaid Coverage?
Many factors determine if you qualify for Medicaid. One of the factors is financial eligibility. Medicaid bases eligibility on Modified Adjusted Gross Income (MAGI), which is your income before taxes. MAGI determines eligibility for children, low-income adults, low-income families, and pregnant women.
Some individuals are exempt from MAGI rules. These include the disabled, people 65 or older, and children who are under the adoption assistance agreement or Title IV-E adoption subsidies.
Individuals who do not qualify under financial need may still qualify as “medically needy.” This category includes pregnant women. They will be covered during pregnancy and for a while after they give birth. Others who qualify as medically needy are those whose income is too high to qualify for Medicaid but have significant healthcare needs. This includes individuals who are blind or who have other disabilities, such as developmental disabilities, physical disabilities, or cognitive issues.
Some parents may not qualify for Medicaid because their income is too high. However, their children younger than 18 will qualify. In this case, the coverage extends only to any child under 18 in the household. Seniors who need long-term care services, such as nursing home care, may qualify if they meet certain income requirements.
While Medicaid is typically reserved for U.S. citizens, sometimes non-citizens become eligible, too. Some categories of non-citizens include refugees, green card holders, and those seeking asylum.
Finally, the Affordable Care Act (ACA) did allow states to expand their Medicaid eligibility. Not all states expanded Medicaid, however. The Affordable Care Act (ACA) allowed states to expand Medicaid eligibility to include low-income adults under age 65 with incomes up to 138% of the federal poverty level, $20,120 for an individual. As of 2023, 40 states and the District of Columbia have chosen to expand Medicaid eligibility.
Options if You Are Not Eligible for Medicaid
If you don’t qualify for Medicaid and want treatment for your SUD, look for free or discounted detox programs. Nonprofit organizations fund some rehab centers. After detoxing, you can find peer support through Narcotics Anonymous (NA) meetings. Although these groups don’t offer individual counseling, community support can be invaluable in helping people maintain a sober lifestyle.
Our National Rehab Hotline Services
When you need free and confidential 24/7 help for an SUD, call our National Rehab Hotline. Our team of caring professionals can listen and provide the necessary resources to get you the help you need for a drug or alcohol addiction. In addition, they can offer treatment solutions and crisis intervention services. Our specialists can also help point you toward a drug rehab center that suits your needs.
If you or someone you love is struggling with a substance use disorder, call our 24/7 hotline today, 866-210-1303.