Medi-Cal

Medi-Cal Insurance

Medi-Cal is a Medicaid program in the state of California that offers free or low-cost health coverage for families and individuals with limited income and resources. Members who are eligible and struggling with alcohol or drug abuse can receive substance use disorder (SUD) services at a Drug Medi-Cal certified program. Many of Medi-Cal’s services, including those for treating substance use disorders, are made accessible through waiver programs.

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Policy Coverage for Substance Abuse

In 2015 the federal government approved California’s Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver amendment. The approval expanded services to include more individuals and requires evidence-based practices be more readily available for treatment of SUDs. The DMC-ODS is a project to expand services such as, “case management, multiple levels of residential SUD treatment, withdrawal management, recovery services, physician consultation, and the option to provide medication-assisted treatment (MAT) and partial hospitalization,” according to the California Health Care Foundation.

The Affordable Care Act (ACA) guarantees that all Medicare health plans offer Essential Health Benefits (EHB) including:

• Outpatient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental Health and Substance Use Disorder services
• Prescription drugs
• Rehabilitative services and devices
• Laboratory services
• Preventative and wellness services and chronic disease management

The following SUD services are available for beneficiaries who live in an opt-in DMC-ODS county:

• Outpatient services
• Intensive outpatient services
• Residential treatment (multiple levels of care for all enrollees and no bed limitation)
• Withdrawal management
• Narcotic treatment services
• Recovery services
• Case Management
• Physician consultation
• Additional medication assisted treatment
• Partial hospitalization

Beneficiaries who do not reside in an opt-in DMC-ODS county have the following benefits available:

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

Does Medi-Cal Cover Outpatient Substance Abuse Treatment?

If you have coverage under Medi-Cal you may have the option of either outpatient services or intensive outpatient services (also known as intensive outpatient programs or IOPS) depending on the county you live in. IOPS require increased time spent within treatment and involves more counseling and therapy sessions, while still allowing clients to keep their jobs and live at home.

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Does Medi-Cal Cover the Cost of Treatment at an Inpatient Rehab Center?

If you live in a county that offers the DMC-ODS waiver, you may be eligible for treatment at an inpatient drug rehabilitation center. The DMC-ODS criteria requires that short-term residential services, or those up to 90 days, be available.

Opioid Medicated Assisted Treatment in California

California has implemented protocols which make buprenorphine more accessible within the state. Suboxone, a medication used to treat cravings and symptoms of opioid withdrawals, is made of buprenorphine and naloxone. A Treatment Authorization Request (TAR), or prior authorization, is no longer required by Medi-Cal for most buprenorphine medications, although a DEA waiver and a diagnosis of opioid addiction are necessary to obtain the medication.

Suboxone is a beneficial medication for medically assisted treatment and easier access to it in a timely manner can help someone begin their road to recovery sooner.

How Can I Pay the Costs Not Covered By Medi-Cal?

Paying for addiction treatment can be stressful but it doesn’t have to stop you from getting the treatment you deserve. Contact one of our treatment providers who can connect you with the right treatment center and help you understand any costs you may need to cover on your own.