The process of seeking treatment for substance use disorder can be intimidating. Deciding which rehab plan is the best for your individual needs is often confusing. Furthermore, the cost can easily become a serious issue.
You’ll likely need to enter either an outpatient or inpatient rehab program. However, many people who want to get help are not sure how to pay for the necessary treatment. You may be wondering what will happen if rehab is not covered by your insurance. Rehab programs are indeed expensive, but there are options for low-income individuals.
Those who are battling a substance use disorder should not suffer simply because they do not have enough money to cover the treatment. There are ways you can pay for your rehab including with Medicaid.
The Affordable Care Act
When the Affordable Care Act passed, every health insurance company was required to pay the costs associated with substance use and mental health disorders. In the past, the majority of policies excluded these costs. The expansion of Medicaid by the ACA enabled millions of individuals living in the United States to finally receive help with the cost of treatment.
If you have previously been unable to afford the costs of rehab, you have an opportunity to receive help through Medicaid. There are several factors used to determine if you are eligible, including:
• Your household size
One of the biggest differences between traditional health insurance and Medicaid is you can enroll for Medicaid throughout the year. There is no enrollment period designated for Medicaid. Once you’ve provided all the information required, your application is generally processed within a period of 45 days. After you’re approved, a review of your eligibility is conducted on an annual basis.
Getting Treatment Through Medicare or Medicaid
For low-income individuals, the most frequently used methods to pay for substance use disorder treatment are Medicare and Medicaid. These are both health insurance programs funded by the state and federal governments. While Medicare is an insurance program the primarily serves people over 65, Medicaid is an assistance program available for low-income people of every age. If you need treatment for a substance use disorder, you may qualify for a low-cost or free treatment through Medicaid.
Coverage Through Medicaid
Each state administers Medicaid individually, with the federal government providing assistance. Individual programs are developed by every state within federal guidelines. The state determines the duration, type and scope of services.
Under most circumstances, part or all of the costs for alcohol or drug rehab and treatment are covered by Medicaid. If you require assistance with the costs, check with Medicaid to determine if you are eligible. Your eligibility rules are dependent on your state of residence. These rules can change every year. If you were denied Medicaid in the past, you may be eligible now.
Substance Use Disorders
SUDs, or substance use disorders, are impacting the lives of millions of individuals living in the United States. This includes people already enrolled in Medicaid. Almost 12% of all Medicaid enrollees above the age of 18 are suffering from a substance use disorder. Here are some other facts to consider about SUDs:
• Drug overdoses are responsible for approximately 105 deaths in the United States every day.
• Every day, more than 6,748 people in the United States are brought to the emergency room due to the misuse of drugs.
• The cost of substance use disorders for society is extremely high. More than $24 billion was spent by health insurance companies for treatment in 2009. Of this amount, over 21% was from Medicaid.
• There is strong evidence the proper management of substance use disorders can effectively manage the associated costs.
• Medication-assisted treatment or MAT decreases medical costs an average of 30% for health care settings including emergency rooms, hospitals and outpatient centers.
• Pregnant women receiving medications for the treatment of substance use disorders stay in the hospital for a much shorter period of time than pregnant women not provided with MAT.
• The cost of health care for individuals with substance use disorders not receiving treatment is approximately double compared to those receiving treatment.
• Costs can be significantly lowered for younger individuals suffering from substance use disorders by providing early treatment. The pre-treatments costs for adults with the same issues are significantly higher.
• Individuals suffering from a dependence on alcohol do not require as many inpatient admissions due to MAT. Healthcare costs for individuals provided with MAT are 30% lower than those without.
• Due to the encouragement of CMS, numerous states are developing strategies to effectively benefit the population. Certain state plans and Medicaid care waivers now include coverage for substance use disorders.
Using Medicaid for Substance Use Disorders
Although Medicaid pays for substance abuse treatment, not all treatment facilities accept Medicaid. If you have been approved to receive Medicaid, make certain the facility you select is covered by the program. Some of the typical Medicaid qualifications include:
• Below the age of 65
• Have at least one child
• Earnings below an income threshold
Certain states offer Medicaid coverage for all adults below a specific level of income. If you’re currently receiving Supplemental Security Income, your eligibility for Medicaid is automatic. The Affordable Care Act may or may not offer you assistance. The ACA has mandated your earnings must be below 133% of the federal poverty level to qualify for Medicaid.
Even if you are currently over the poverty level, you may qualify for government assistance through Medicaid. On the other hand, you may still be denied Medicaid even if your income qualifies. Your acceptance is dependent on the individual rules established by each state.
Applying for Medicaid
If you intend to apply for Medicaid, you can do so at any time through either the health insurance marketplace or the Medicaid website for your state. You must be able to provide the documentation required by your state of residence. The most frequently requested documents include:
• A driver’s license or birth certificate
• Recent tax return or pay stubs
• Medical records
• Proof you are living at your current address
• Bank statements
Your state has a maximum of 45 days for processing your application. If you have a disability, this increases to 90 days. If you are unable to qualify for Medicaid, you may be able to receive a subsidized plan during open enrollment for the federal marketplace.
What Medicaid Will Cover
If you are approved for Medicaid, the majority of states do not require co-payments to treat substance use disorders. Some states will require you to pay the maximum out-of-pocket expenses for Medicaid recipients. Medicaid currently pays more for substance use and mental health disorders in the United States than any other carrier.
In 2008, Congress passed the Mental Health Parity and Addiction Equity Act into federal law. The MHPAEA requires coverage for both substance use and mental health disorders that are equal to coverage generally provided for other medical issues. This law is applicable for:
• The maximum for out-of-pocket expenses including coinsurance and copays
• Covered outpatient visits
• Limiting the use of services such as covered outpatient or inpatient visits
• Using tools for care management
Although there is a maximum for out-of-pocket expenses, the majority of individuals receiving Medicaid do not have to pay co-pays to receive treatment for a substance use disorder. Part or all of the following services are covered by Medicaid:
• Inpatient care
• Family counseling
• Outpatient care
• Medications and maintenance therapy
• Residential treatment for the long-term
Additional costs can be imposed by the state including coinsurance, copayments, and deductibles for the majority of outpatient and inpatient benefits. The amount you are charged may be in direct relation to your income.
If you or someone you love is suffering from a substance use disorder, you may require an intensive therapy program for rehabilitation including supervision by a physician. Your care is coordinated through a team of therapists and physicians working together. Medicaid may cover:
• Rehabilitation services
• Occupational therapy
• Physical therapy
• Speech-language pathology
• Nursing services
• Semi-private room
• Additional hospital supplies and services
Medicaid will not cover:
• A television or phone in your room
• Private duty nursing
• A private room unless necessary for medical reasons
• Personal items including socks, and toothpaste unless part of an admission pack
Medicare for Substance Use Disorders
If you have a disability or are above the age of 65, you should be able to receive Medicare. You will be required to pay a premium each month based on your income. If your income is lower, your premium is decreased. Medicare will cover your costs for both outpatient and inpatient rehabilitation. Your recovery program is covered by Medicare under four separate parts.
Medicare Part A: Part A covers your hospital stays. You may also receive coverage for inpatient rehabilitation. You’ll get coverage for a maximum of 60 days of treatment with no co-insurance payment. When you use Part A, no deductible is required. The coverage you receive for your entire life pays for a total of 190 days in inpatient care.
Medicare Part B: Part B is your medical insurance. You may be covered for a maximum of 80% of the cost of outpatient care for a substance use disorder. Part B covers your therapy, outpatient care, professional interventions, and drugs received at a clinic. You are also covered for co-occurring disorders such as depression.
Medicare Part C: Part C is your private insurance approved by Medicare. If you’re interested in receiving additional benefits, you can sign up for Part C. The cost of your coverage may be higher due to several factors including the specific coverage, costs and out-of-pocket expenses.
Medicare Part D: This is your insurance for prescriptions, and it will help with your cost for extra medications. While in recovery you will most likely require medication for your cravings and the management of your withdrawal symptoms. Your chance of remaining sober increases when these medications are used.
You can be eligible for both Medicare and Medicaid. If you are approved for both, benefits can be applied to your treatment from both programs. If you have a disability or are above the age of 65, you may be accepted to both programs. If you do not currently have either Medicare or Medicaid, contact a caseworker in your state for assistance.
A caseworker can determine whether or not you are eligible for one or both programs. If you are qualified, your caseworker will help you with the application process required for both programs.
Programs at Green Mountain Treatment Center
Located in Effingham, NH, Green Mountain Treatment Center offers residential addiction treatment within a secluded country environment. Our adult-oriented and gender-separate facility utilizes a 12-Step curriculum that’s integrated into individualized treatment plans.
If you already have Medicaid, Medicare or both, you can check with Green Mountain Treatment Center to find out if your coverage is accepted. We’ll be happy to provide additional information regarding your options for recovery.