Does Your Insurance Cover Rehab?

Passed in 2010, the Patient Protection and Affordable Care Act (ACA) was designed to give Americans more access to addiction treatment services. If the bill’s official title doesn’t sound familiar, you’ll likely recognize its informal title: Obamacare. The real power of the ACA comes in the form of massive coverage expansion, regulatory changes for existing insurance plans, and requiring insurance providers to evaluate alcohol and drug rehab needs in the same way they traditionally evaluate any other medical or surgical procedure. Obamacare gives you affordable access to a wealth of addiction treatments by forcing insurance companies to offer full or partial coverage for those treatments.

Many private insurers still don’t cover pre-existing medical conditions – alcohol and drug addiction being two common examples. Thanks to the ACA, however, insurance companies can no longer label drug or alcohol addiction as a pre-existing condition. And since it’s no longer considered pre-existing, they can no longer issue letters of denial for insurance coverage when someone needs to go to rehab for treatment.

You can buy your own ACA health insurance plan on the Health Insurance Marketplace at Healthcare.gov. It’s important to note, however, that some states actually have their own unique versions of the Marketplace. These state-run websites are totally separate from the federal Healthcare.gov site, with the main difference between the two being the amount of Medicare and Medicaid coverage each state offers.

ACA Addiction Treatment Insurance Reforms

Since insurance providers must now treat addiction as a typical medical procedure, the ACA requires insurance companies to cover addiction screening. They also have to provide addiction treatment coverage under all “Essential Health Benefits” packages, including all Medicaid expansion programs and qualified state plans found on state health insurance exchanges.

Coverage for ACA insurance plans include the following:

• Initial evaluation for addiction
• Addiction treatment medications
• Clinic visits
• Alcohol and drug testing
• Family counseling
• Medication-assisted treatment medications
• Medical detox programs

Insurance Plans Offered By Obamacare

Most insurance plans associated with the ACA fit into one of the following four categories – each of which offers a range of payment splits. When visiting the Marketplace, you’ll notice the following purchase options:

Who’s Eligible For Coverage?

Coverage eligibility for ACA is straightforward and has three basic requirements. To enroll, you must:

• Live in the United States
• Be a U.S. citizen or national
• Not be incarcerated

This federal tool can be used to calculate how much, if any, financial assistance you stand to gain through the ACA. As with all insurance plans, coverage amounts are subject to the provider’s terms and conditions.

Paying for Rehab With Medicaid And Medicare

Medicaid and Medicare are federally- and state-funded insurance programs. They may both cover part or all of your substance abuse treatment costs. Every state has different rules for eligibility and treatment coverage, and those rules can change annually. So, if you’ve been turned down for Medicaid or Medicare in the past, it’s possible you might be eligible now.

Medicaid For Drug And Alcohol Rehab

Medicaid is a publicly available insurance program for low-income families. After the ACA was passed in 2010, it forced insurance providers (including Medicaid) to provide coverage for all basic components of alcohol and drug addiction treatment.⁴

While Medicaid does cover substance abuse treatment, it’s worth mentioning that not all facilities accept the insurance as a form of payment. 

Medicaid Eligibility

To qualify for coverage under the Medicaid program, applicants must be one of the following:⁴

• Over 65 years old
• Under 19 years old
• Pregnant
• A parent
• Within a specified income bracket

Some states offer Medicaid to all adults falling below a certain income level. 

What Does Medicaid Cover?

Every state Medicaid program provides some level of coverage for addiction treatment, generally including:³

• Screenings
• Intervention
• Maintenance and craving medications
• Family counseling
• Inpatient care
• Long-term residential treatment
• Detox
• Outpatient visits
• Other mental health services
• Inpatient addiction treatment
• Outpatient addiction treatment

Medicare For Drug And Alcohol Rehab

Medicare is available to anyone over 65 years old and those with certain disabilities. The monthly cost is based on your income, meaning the less you earn, the lower your premiums.⁵ 

Medicare also covers inpatient alcohol and drug addiction treatment, as long as a doctor says it’s “medically necessary.” However, you must opt for treatment at Medicare-approved inpatient treatment facility. You’ll want to do some research in order to locate a facility that accepts Medicare.

Outpatient treatment falls under Medicare Part B, which includes partial hospitalization programs (PHPs). PHP programs allow you to attend a treatment center for intensive treatment and counseling during the day, but you’re able to return home at night.⁵

Medicare parts and their rates of coverage for addiction treatment include:⁵

• Medicare Part A helps cover the cost for inpatient rehab. With Part A, you’ll receive coverage for up to 60 days without a co-insurance payment. You’ll be responsible for a deductible, however. Medicare will cover up to 190 days of inpatient addiction treatment in your lifetime.
• Medicare Part B covers up to 80 percent of outpatient addiction treatment costs. This includes outpatient care, therapy, medications administered, and professional intervention services. Part B also covers treatment for co-occurring disorders.
• Medicare Part C offers more benefits than standard Medicare alone. Out-of-pocket costs and the amount of coverage are different and may ultimately be more expensive.
• Medicare Part D helps to cover the cost of medications required for addiction treatment. For example, medications are often needed to manage withdrawal symptoms and cravings.

Resources

1. Key Substance Use and Mental Health Indicators in the United States: Results From the 2015 National Survey on Drug Use and Health. Bethesda, MD: Substance Abuse and Mental Health Services Administration; 2016.
2. What’s included as income. (2019). HealthCare.gov. https://www.healthcare.gov/income-and-household-information/income/
3. Substance Abuse and Mental Health Services Administration. (2014 November). Medicaid Coverage and Financing of Medications to Treat Alcohol and Opioid Use Disorders.
4. Medicaid.gov. (2021). Eligibility.
5. Disclaimer Medicare Coverage of Substance Abuse Services. (n.d.).Centers for Medicare & Medicaid Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1604.pdf‌