How to Use Medicare or Medicaid to Pay for Your Treatment

How to Use Medicare or Medicaid to Pay for Your Treatment

Outpatient addiction care is a crucial step to getting your life back on track. Even if you’ve already completed inpatient treatment, ongoing outpatient treatment can help you stay clean as you return to your everyday life.

You may have multiple options for paying for your treatment. Medicare is a federal benefit program designed for seniors and people with disabilities. Medicaid is a program for low-income people that is largely regulated by federal law, but your state may have its own rules about eligibility and costs.

Even if you already have insurance, you could gain additional benefits by applying for Medicare or Medicaid. There are some restrictions on using these programs, but they pay for most outpatient addiction treatment services and Suboxone doctor appointments.

Applying for Medicare

medicaidIndividuals can apply for Medicare if they are over 65 or if they have certain disabilities under the age of 65. Medicare is broken down into Part A, Part B, Part C, and Part D. Many seniors only have parts A and B, since parts C and D are optional.

Part B covers outpatient treatment, while Part D typically prescription medications. Part C is a private-sector version of Medicare called Medicare Advantage, which often also includes Part D. For outpatient addiction treatment, you may use both Part B and Part D, and may use Part C depending on the type of Medicare Advantage coverage you have.

Most seniors over 65 are required to apply for Medicare Parts A and B. If you haven’t applied yet, sign up as soon as possible to get the benefits. If you are disabled, the application process may take several weeks, unless you are already receiving Social Security benefits.

You can apply for Medicare online or contact your Social Security office if you are already receiving those benefits. Medicare is not automatic once you turn 65, so you need to apply. You can apply up to 3 months before your 65th birthday.

Applying for Medicaid

Household income limits are based on family size, and change slightly from year to year. The list of eligible disabilities also varies, and partial or temporary disabilities may not qualify.

You can start an application for Virginia Medicaid or North Carolina Medicaid online. Applying for Medicaid may take time, due to the processes required to verify your income, family size, and disability levels.

Virginia and North Carolina typically require new Medicaid applicants to apply during Open Enrollment periods in November and December of each year. However, you may qualify for Special Enrollment if you have recently had a change in employment or income, or have recently become pregnant or disabled.

What if I Already Have Insurance?

If you already have health insurance when you apply for Medicare, Medicare will become your primary insurer. All medical expenses will be submitted to Medicare first, with the remainder then sent on to your private insurance. Generally, you should not need to complete additional paperwork for this process to occur after each appointment.

Individuals who are insured through their employer but are eligible for Medicaid may qualify for assistance paying for premiums. Your addiction treatment would then be covered by your existing insurance, not by Medicaid.

Appointment Eligibility

Medicare only pays for medically necessary treatment, so you may need to consult with your primary care physician or schedule an initial consultation with our treatment center to confirm your eligibility. Your doctor may also need to contact Medicare or Medicaid administrators for prior authorization for certain treatments. However, as a general rule, doctors appointments are covered by Medicare Part B and Medicaid.

Typically, Medicare and Medicaid require patients to attempt outpatient treatment before they agree to cover inpatient options. Trying outpatient treatment first allows you to avoid large bills that aren’t covered by your insurance. If you have already completed inpatient treatment, Medicare and Medicaid continue to cover outpatient services as long as they are medically necessary.

When booking your first outpatient appointment, inform the staff that you are using Medicare or Medicaid. They need your member ID number and possibly other paperwork to ensure your coverage is current. Once your information is on file, you generally won’t need to update it unless your coverage levels or other personal information changes.

Prescription Coverage

prescription coverageSuboxone and other treatments administered in-office are covered under Medicare Part B. However, any other medications such as antidepressants or anxiety medications are covered under Medicare Part D. Most Medicare Advantage plans include Part D prescription coverage.

Medicaid covers medically necessary medications, including any mental health medications your addiction treatment doctors may prescribe. Copayments are generally less than $5 per medication and are usually due at the time you pick up the prescription.

In some cases, Medicare and Medicaid have to authorize prescriptions before a doctor can write them. Virginia and North Carolina Medicaid each have lists of pre-approved prescription drugs, but some doctors may want to prescribe additional medications. Your addiction treatment center can work with you to determine medications that work best for you under your insurance plan.

Therapy Coverage

therapy coverageIn principle, insurers are required to extend the same coverage to mental health services as they do to physical health services. This means that therapy related to substance abuse may still be covered as long as the therapy is deemed medically necessary.

Like with other types of treatment, therapy may still require copays or fall under a general deductible. Your exact amount of coverage varies based on your specific situation. You may receive bills in the mail after the appointments or may owe a small copayment at the time of service.

Addiction Treatment Doctors Near You

Right Path Addiction Centers work with you to set a Suboxone treatment plan and therapy sessions that keep you on track to stay sober. We have convenient and discreet locations that make it easy for you to maintain your everyday life while getting treatment. We can help walk you through your payment and treatment options under Medicaid and Medicare.


imageWritten by Sergey Zhitar, MD Medical Director

Native of Moldova, Dr. Zhitar is Board Certified in Addiction Medicine as well as Internal Medicine and completed his training at UPMC Shadyside, Pittsburgh, PA in 2000.

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