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Updated on January 27, 2022

Medi-Cal Insurance For Addiction Treatment

What is Medi-Cal?

Medi-Cal is the State of California’s Medicaid system.

It provides health insurance to low-income individuals and families in California. Program participants have access to free or low-cost healthcare coverage. This includes treatment for alcohol and drug addiction.

Many Medi-Cal enrollees pay no premium, co-pay, or out-of-pocket costs for care. In other cases, premiums cost $13 per person with a $39 monthly maximum.

Medi-Cal recipients usually have access to the same benefits as Covered California (California’s Health Insurance Marketplace) but at a reduced cost.

Who is Eligible for Medi-Cal?

To be eligible for Medi-Cal, you must be at least one of the following:

  • Below the Federal Poverty Level (FPL)
  • 65 or older
  • Under 21
  • Blind
  • Disabled
  • Pregnant
  • Living in a skilled nursing home or intermediate care home
  • Have temporary refugee status
  • Diagnosed with breast or cervical cancer
  • A parent or caretaker of a disadvantaged person under 21

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Medi-Cal for Addiction Treatment: What’s Covered?

You might be eligible for the following addiction treatment options if you are covered under Medi-Cal:

  • Outpatient rehabilitation 
  • Emergency services
  • Hospitalization
  • Mental health services
  • Prescription drugs
  • Maternity and newborn care
  • Lab services
  • Preventive and wellness services

Substance use services that might be available under Medi-Cal include:

Coverage varies by county. 

Medi-Cal recipients might be eligible for MAT coverage for:

MAT medications require no Treatment Authorization Request (TAR) or prior authorization. You’ll need a Drug Enforcement Administration (DEA) waiver and an opioid addiction diagnosis in some cases.

What Isn’t Covered?

To participate in federal Medicaid programs, state programs like Medi-Cal must cover certain services, including:

  • Early intervention 
  • Traditional outpatient services
  • Intensive outpatient services
  • Short-term residential services up to 90 days 
  • Withdrawal management
  • Opioid/narcotic addiction treatment
  • Recovery help
  • Case management
  • Physician consultations

Medi-Cal might not cover some of these services. Program participants coordinate additional services based on their individual physical and mental health care needs. 

You might need documentation for some Medi-Cal health care services. A medical professional must diagnose a substance use disorder (SUD). There must also be evidence that shows SUD treatment is necessary for recovery.

In most cases, approval of substance abuse treatment services requires a substance abuse assessment. This confirms the diagnosis and establishes appropriate and necessary treatments. 

DMC-ODS

The federal government approved California’s Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver amendment in 2015. 

This expanded the program to include more people and make evidence-based practices more readily available for addiction treatment. 

DMC-ODS expand services including: 

The following addiction treatment services are available for beneficiaries living in an opt-in DMC-ODS county:

Medi-Cal recipients not living in an opt-in DMC-ODS county have the following benefits available:

  • Outpatient services
  • Intensive outpatient services
  • Perinatal residential treatment
  • Narcotic treatment program services

This means there might be some services Medi-Cal won’t cover for people living in certain counties in California.1

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Paying for Uncovered Rehab Costs 

Medi-Cal offers health insurance coverage for low-income individuals and families in California. Occasionally, there are out-of-pocket costs for health care services.

This is often the case for individuals who need extended substance abuse treatment (90 days or more).

Rehab centers often use a sliding-fee scale or payment program to make out-of-pocket costs more affordable.

In some cases, Medi-Cal does not cover medications. This is why you should undergo a clinical assessment before treatment. It will help determine your financial responsibility for treatment beforehand.

Many facilities offer or accept scholarships, grants, personal loans, or other payment arrangements to help people get the treatment they need. 

Some facilities restrict the number of Medi-Cal admissions because the reimbursement rate is usually significantly lower than other insurance carrier rates.

Call to find out how much your insurance will cover
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Resources

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  1. Drug Medi-Cal Organized Delivery System.” Department of Health Care Services (DHCS). 
  2. Medi-Cal and Covered California Frequently Asked Questions.” Department of Health Care Services (DHCS). 
  3. Services.” Department of Health Care Services (DHCS).
  4. BHS.” Department of Health Care Services (DHCS). 
  5. Adult: California Mental Health Cooperative Programs Employment with Support.” Department of Health Care Services (DHCS). 
  6. HealthCare.gov. “Federal Poverty Level (FPL) - HealthCare.gov Glossary.

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