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Healthcare Coverage for Substance Use Disorder

Health Insurance Medicaid & Medicare

Your health plan may cover treatment for Substance Use Disorder.

Learn about how your health plan may cover treatment for Substance Use Disorder. Private insurance must cover certain treatments. Medicaid, Medicare, and Veteran Affairs benefits also provide coverage.

What medications are used for Opioid Use Disorder (OUD)?

Medications for Opioid Use Disorder (MOUD) are  special medicines that affect the brain. These medicines used to be called Medications for Addiction Treatment, but recently they have been renamed as MOUD. Treatment that combines medicine and therapy to help stop using substances is called Medication-Assisted Treatment. Studies have shown that using medicine and talking to a therapist or counselor is more helpful than using medicine alone.

There are three U.S. Food and Drug Administration-approved medications used to treat OUD: 

  • methadone
  • buprenorphine 
  • naltrexone

Does Medicare cover OUD treatment?

Medicare helps pay for OUD treatment.

Part A helps pay for methadone treatment for people in the hospital.

Part B covers special treatment programs. Special medical clinics called Narcotic Treatment Programs, also known as Opioid Treatment Programs or Opioid Treatment Centers, help people who are dependent on narcotics or opioids. These clinics give patients medicines like methadone or buprenorphine and also provide therapies to help them. You can find a list of opioid use treatment service providers in Texas here.

Part D covers the cost of medicines like buprenorphine and methadone.

What does a Medicare patient need to pay for treatments?

If you see a doctor enrolled in Medicare, you will not have a copay.  This includes counseling, therapy, and regular check-ins with the doctor, both in person and virtually.

Medicare Part B covers OUD medications and treatment but the rules are complicated and you may need to pay a deductible for office visits and medication copays.

Does Medicaid cover OUD treatment?

Medicaid covers the cost of medicines approved by the Food and Drug Administration for OUD.

In Texas, Medicaid covers methadone, buprenorphine, and naltrexone. You can get methadone if you are in counseling for Substance Use Disorder. Medicaid also covers other medicines, like suboxone and naloxone. You can get these medicines from special programs or your doctor’s office.

Texas Medicaid also covers evaluations and counseling for OUD, as well as for other non-opioid Substance Use Disorders.

Depending on your income level, medication will cost either up to $8 or up to 20% of the drug cost. Medicaid will decide how much your share of the cost will be.

Does the VA cover OUD treatment?

Veterans who receive VA benefits qualify for both detoxification programs to stop using substances, and therapies and medicines that reduce your desire to use substances. Doctors will evaluate you in order to determine what help you need. VA benefits include short-term outpatient counseling, intensive outpatient treatment, self-help groups, and prevention care.

Does private health insurance cover OUD treatment?

Private insurance plans must cover Substance Use Disorder treatments, including treatment for OUD. The Affordable Care Act, commonly known as Obamacare, expanded health insurance coverage for mental health treatment. Therapy, counseling, copays, and coverage for Substance Use Disorder must be similar to those offered for other health problems.

However, some private plans do not cover all medications for OUD. Many plans also have deductibles and copays of 20% per visit. Some plans require you to talk to a doctor before starting the medication. If you do not speak to a doctor first and get evaluated, they may ask you to pay the whole cost yourself. Contact your insurance provider to find out if you need a doctor referral and how much of the total cost the plan covers.

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