Simply making the decision to seek treatment or convincing a loved one to get help is extremely difficult and is a process plagued by anxiety and fear. And that’s before you even begin the overwhelming task of choosing the best treatment plan.
Then, as you start to research the wide variety of available facilities or choose between an inpatient or outpatient program, you run smack into a huge road block–cost.
How will you pay for treatment? Will health insurance cover the costs? And what if you don’t have health insurance? What then?
On average, programs can cost anywhere from $10,000 to $21,000. These high costs are extremely discouraging. Not being able to get needed treatment or watching a loved one continue to suffer due to a lack of funds to pay for care can be devastating.
But here’s some good news: With the passing of the Affordable Care Act, for the first time ever, all health insurance plans must cover mental health and substance use disorder services.
And here’s even better news: The ACA expands Medicaid to include millions more Americans. If you or a loved one hasn’t been able to afford health insurance in the past, joining the program will provide you the opportunity to get the help you need.
Of course, sifting through the many websites and articles about the program and its coverage opportunities can be downright overwhelming. Following is a guide that helps simplify the process by breaking down the information you’ll need into bite-size, easy-to-understand pieces so that you (or a loved one) can start on the path to recovery right away.What is Medicaid? This government-sponsored program helps millions of Americans cover their healthcare costs. Many qualify–including families, children, pregnant women, childless adults, seniors, and people with disabilities.Do you qualify? Your eligibility is determined by a few factors, including the number of people in your household, income, age, disability, etc. Unlike other forms of health care coverage, you can enroll any time of the year. There is no designated enrollment period. You can check to see if you or a family member are eligible here.
How long does the application process take? LongTermCare.gov provides helpful information on the application process. It explains that when you provide all of the required information it usually takes 45 days to process your application. If you’re approved, your eligibility will be reviewed each year.What is CHIP and how do you enroll your child? CHIP is the Children’s Health Insurance Program. As InsureKidsNow.gov explains, it is designed to provide health care coverage to children up to age 19. If you are a family of four with an income of $48,500 or less, your children can most likely get coverage.
What is the Medicaid Expansion? As part of the Affordable Care Act, state governments were provided additional federal funding for their Medicaid programs, allowing states that accepted the expansion to cover adults under 65 up to 133% of the federal poverty level. If your state took the expansion, learn your options.
My state didn’t extend Medicaid. What does that mean for me? If your state didn’t take the expansion, your health coverage options will depend on your income. Healthcare.gov recommends that you first apply to see if you qualify for federal or state assistance. If you aren’t eligible, you may be able to buy a plan in the Marketplace and receive tax credits to help you pay for your coverage.
What should you do if your service or treatment is denied? As NOLO.com explains, all beneficiaries have the right to appeal denials. The article explains what steps should be taken in the event of a denial. For example, first, “write a simple appeal notice” and “submit it in person to your local state Medicaid agency office.”
Can you receive coverage if you aren’t a U.S. citizen? The short answer is maybe. For those who aren’t U.S. citizens or have loved ones who aren’t U.S. citizens who are seeking coverage, the Legal Aid Society of the District of Columbia provides helpful information on who can receive coverage without citizenship. For example, if you are a lawfully-residing child, pregnant woman, and or “qualified immigrant,” you may be eligible.
Can you receive coverage if you’re homeless? Yes. The U.S. Interagency Council on Homelessness and the National Health Care for the Homeless Council released “Medicaid Enrollment: Your Guide for Engaging People Experiencing Homelessness,” which explains how the expansion will help more homeless people get medical coverage.What is covered? As Medicaid.gov notes, the program is the single largest payer for mental health services in the United States and is increasingly playing a larger role in the reimbursement of substance use disorder services. Opportunities for coverage are constantly evolving.
Most recently, the Mental Health Parity and Addiction Equity Act passed and extended Behavioral Health Services coverage to beneficiaries participating in Managed Care Organizations, State alternative benefit plans and the CHIP. Medicaid.gov provides comprehensive information about its Behavioral Health Services coverage for children and youth and others with substance abuse disorders.
What are the specifics of coverage in your state? Because some states accepted the expansion and some didn’t, you might be uncertain on whether you or your loved one qualifies. One way to determine eligibility is income level. If you’re an individual who makes less than $16,243/year, then you may qualify. You can also use the State Medicaid & CHIP Profiles map to find out if your state accepted the expansion, enrollment data, and how to apply.
Rehabs that accept Medicaid: Periodically, the Centers for Medicare and Medicaid Services (CMS) releases Informational Bulletins on effective practices for treating substance abuse disorders. Here are two examples:
- Rehabs That Accept Medicaid for Substance Use Disorders
- Delivery Opportunities for Individuals with a Substance Use Disorder
How can you get substance abuse treatment for your child? Rehabs that accept Medicaid and CHIP do provide behavioral health services and substance use treatment coverage to children. The programs have released Informational Bulletins that explain the extent of this coverage:
- Coverage of Behavioral Health Services for Youth with Substance Use Disorders
- Dept. of Health and Human Services’ Federal Guidance Policy Letter on Trauma Screening
For additional information on getting the best substance abuse treatment for your child, the Partnership for Drug-Free Kids provides the Treatment eBook: How to Find the Right Help for Your Child with an Alcohol or Drug Problem.
Are there Rehabs that Accept Medicaid? To find a rehab that accepts Medicaid, use the Substance Abuse and Mental Health Services Administration’s Treatment Services’ Locator. Each facility listed comes with information regarding the kinds of insurance it will accept.
Will Medicaid cover court-mandated rehab? The National Drug Court Institute’s Ensuring Sustainability for Drug Courts: An Overview of Funding Strategies explains that reimbursement has depended on the state in the past. Some states will reimburse court-ordered treatment; while in others, funds have been provided by local governments to the state to match federal Medicaid funds.
What if you or your loved one have too much income to qualify? If you or your loved one is under 21, over 65, disabled, or blind, or part of a family where one or both parents are absent, deceased, or unemployed, you may be able to “spend down” to qualify. The New York State Education Department explains that if someone has too much income to qualify for Medicaid, they may be able to get coverage through the program when they spend the excess income on medical bills.
Looking to the Future – Areas That Need Improvement
Provide coverage for those coming out of prison. If you or someone you love is exiting the corrections system and is in need of on-going substance abuse treatment, know that efforts are being made to bridge the gap in coverage for this population. CMS’s Technical Assistance Brief “Coverage and Delivery of Adult Substance Abuse Services in Medicaid Managed Care” explains which states are making strides in helping these oft-neglected individuals and points out that there is still room for progress.
Increase knowledge of early identification programs. It is important for parents to know about the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Benefit. As part of EPSDT, children who receive health care coverage via a government-sponsored plan are eligible for age-appropriate mental health and substance use health screenings.
Repeal bed-limit law. The ACA mandated that insurance plans cover mental health and substance abuse treatment. However, a recent New York Times article explains that a 50-year-old law still on the books restricts the kinds of places where beneficiaries can get treatment. It limits coverage to only community-based facilities with 16 or fewer beds.
Increase the number of providers. An article from The Pew Charitable Trusts addresses a key barrier to receiving adequate substance abuse treatment–a lack of providers. As the article notes, because these services weren’t covered by insurance plans, behavioral health providers were paid less than other medical professionals. As result, many have ended up in “more lucrative specialties.” However, the passing of the ACA means it’s time for the industry to take steps to meet the new demand.
Improve prevention efforts. The Office of Disease Prevention and Health Promotion’s Healthy People 2020 provides “science-based, national objectives for improving the health of all Americans.” One topic it addresses is how to reduce substance abuse. It provides statistics-supported information:
Continue to expand distribution of TIPs. SAMHSA produces Treatment Improvement Protocols (TIPs), which provide guidelines for improving substance abuse treatment. The National Center for Biotechnology Information explains that TIPs are distributed to a growing number of facilities and individuals across the country. Examples include: