Under the Affordable Care Act, many individuals who need mental health coverage can get the help they need through these government health care programs.
Medicare provides coverage primarily for individuals aged 65 and older while Medicaid serves to help individuals and families who cannot pay for health costs
on their own.
When comparing Medicare vs. Medicaid coverage, it’s important to know that they overlap in some areas, but ultimately function very differently. Here’s what you need to know.
Medicare is governed by the federal government. When it comes to substance abuse recovery services, there are different types of benefits that you may be able to use.
Outpatient and Inpatient Rehab
Part A: Inpatient
Part A of Medicare
helps cover drug or alcohol rehab treatment if you need to stay as a hospital inpatient. This includes your room and meals.
For Medicare, hospital services are measured in benefit periods. Each benefit period begins when you’re admitted to the hospital as an inpatient. It ends after you’ve been outside of hospital care for 60 days. That way, if you need to return to the hospital multiple times in a close time period, you won’t need to pay a new deductible (the amount you pay on your own before Medicare kicks in).
If you’re at a general hospital, there’s no limit to your number of benefit periods. However, at a psychiatric hospital, Medicare will only cover 190 days as an inpatient for your lifetime.
Part B: Outpatient
Under Medicare Part B, you’ll have health care as an outpatient, provided by a hospital. This can also include visits with your psychologist or clinical social worker, lab tests, and even partial hospitalization services in some circumstances.
Your deductible will vary between 20-40% of the amount, as long as the amount is approved by Medicare.
Part D: Medication
Part D can help cover prescription drugs needed to treat mental health conditions, such as Methadone
and anti-seizure medications.
Structured Assessment and Brief Intervention (SBIRT)
Medicare also offers a different approach for individuals who are facing substance abuse but don’t have a severe diagnosis. SBIRT
is an early intervention for those who show signs of drug abuse or dependency. It serves to both assess the severity of the addiction and refer the individual to the appropriate level of care.
Many people are automatically enrolled in Parts A and B of Medicare when they turn 65. If you don’t receive this automatically, you’ll likely need to enroll on your own. You can do that at Medicare.gov
To receive coverage for prescription drugs, you’ll need to enroll in Part D separately. You’ll want to do this when you’re first eligible, or else you might need to pay a late enrollment penalty. Learn more about enrolling in Part D here
Even when enrolled in Parts A, B, and D, there will be costs you’ll need to pay on your own that are separate from the deductible. For example, Medicare does not cover transportation
to and from any health care appointments, social support groups (these are different from group therapy), or job training that’s separate from your mental health treatment.
Medicaid is a program that is governed by the state, and therefore, coverage varies depending on which you state you live. It’s designed for individuals with limited income who also are any of these:
- A child under 19
- Living with a disability
- A parent or adult caring for a child
- An adult without dependent children (in some states)
- An eligible immigrant
To learn more about Medicaid eligibility, visit the Medicaid page at Healthcare.gov
What Medicaid Covers
The benefits Medicaid provides vary by state. However, all plans
must include inpatient and outpatient
hospital services. This might also mean it will give coverage for intervention, long-term or short-term rehab, and family counseling. However, some states may not offer coverage for prescription drugs or psychiatric services for those under age 21
For information on the coverage your state offers, you’ll want to contact your state Medicaid agency. See Benefits.gov
for program information for your area.
Spend Down Process
Do you earn too much to qualify for Medicaid? You might still be eligible
under the “spend down” rules. This allows you to subtract your medical expenses from your income and use the final amount to determine eligibility. This will make you eligible as a “medically needy” individual.
Spending down is not available in every state, and it comes with additional restrictions that determine eligibility. The best way to find out the specifics is to call the Medicaid program for your state
In some circumstances, you might be eligible for both Medicare and Medicaid. Individuals in this category are referred to as “dual eligibles.” With coverage from both of these sources, it’s likely that the majority of the health care costs you’ll encounter while seeking substance abuse treatment will be covered.
Are you ready to begin your journey to recovery?
You don’t have to figure it all out on your own. Our specialists are standing by to help you sort through the confusing details.
At The Recovery Village, we help our patients through a full spectrum of care. That means you’ll work with a team from day one of planning your detox through the day you no longer need our help. And to make it even easier, we accept most major forms of insurance. Contact our Admissions team
to learn how we can help.
“Health Insurance Status of Adult Substance Abuse Treatment Admissions Aged 26 or Older: 2011.” The TEDS Report. SAMHSA, 6 Feb 2014. Web. 2 May 2016. <http://archive.samhsa.gov/data/2k14/TEDS134/sr134-health-insurance-2014.htm>.
“Medicaid & Your Mental Health Benefits.” Medicare.gov. U.S. Department of Health and Human Services. Web. 2 May 2016. <https://www.medicare.gov/Pubs/pdf/10184-Medicare-Mental-Health-Bene.pdf>.
“Medicare Coverage of Mental Health and Substance Abuse Services.” Center for Medicare Advocacy. CMA Health Policy Consultants. Web. 2 May 2016. <http://www.medicareadvocacy.org/medicare-info/medicare-coverage-of-mental-health-services/#alcohol_and_substance>.
“Medicare coverage of treatment for alcoholism and drug abuse.” MedicareInteractive.org. Medicare Interactive. Web. 1 May 2016. <http://www.medicareinteractive.org/get-answers/medicare-covered-services/mental-health-services/medicare-coverage-of-treatment-for-alcoholism-and-drug-abuse>.
“When & how to sign up for Part A & Part B.” Medicare.gov. Centers for Medicare & Medicaid Services. Web. 1 May 2016. <https://www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/when-how-to-sign-up-for-part-a-and-part-b.html>
“How to get drug coverage.” Medicare.gov. U.S. Centers for Medicare & Medicaid Services. Web. 1 May 2016. <https://www.medicare.gov/sign-up-change-plans/get-drug-coverage/get-drug-coverage.html>.
“What’s Medicare?” Medicare.gov. U.S. Centers for Medicare & Medicaid Services, June 2015. Web. 2 May 2016.
“Medicaid & CHIP Coverage.” HealthCare.gov U.S. Centers for Medicare & Medicaid Services. Web. 2 May 2016. <https://www.healthcare.gov/medicaid-chip/>.
“Behavioral Health Services.” Medicaid.gov. U.S. Centers for Medicare & Medicaid Services. Web. 2 May 2016. <https://www.medicare.gov/pubs/ebook/pdf/Medicare_and_You-2015.pdf>.
“Medicaid.” Medicare.gov. U.S. Centers for Medicare & Medicaid Services. Web. 2 May 2016. <https://www.medicare.gov/your-medicare-costs/help-paying-costs/medicaid/medicaid.html>.
“Medicaid/Medicare.” Benefits.gov. USA.gov. 2 May 2016. <http://www.benefits.gov/benefits/browse-by-category/category/21>.