Does Molina Healthcare Insurance Cover Substance Abuse?

Molina Healthcare is a managed healthcare company headquartered in Long Beach, California. The company offers healthcare coverage for nearly 4 million people through the implementation of government-based healthcare programs. The company has been in operation for over 30 years. Its primary focus is on providing insurance with state governments through healthcare plans, such as Medicare and Medicaid-based programs as well as some other marketplace exchange programs in some states.

When a person purchases a healthcare policy through Molina via a state exchange or marketplace, the policy is required by the Affordable Care Act (Obamacare) to provide coverage for mental health services, which includes the treatment of substance use disorders. For individuals who do not acquire a plan from Molina through a state market exchange, the Affordable Care Act requires that private policies also provide some provisions for mental and behavioral healthcare, including provisions for substance abuse. Thus, Molina does provide coverage for substance abuse; however, the actual coverage will vary depending on how the policy was acquired, the state where the individual lives, and whether or not the policy was acquired through a public market exchange or privately. In general, coverage should apply to inpatient treatment programs, residential treatment programs, and outpatient treatment programs, but again, the exact coverage will depend on how the individual acquired the policy, the state the person lives, and the policy itself.

Medicaid Programs

Molina offers Medicaid plans in numerous states, including:

  • California
  • Florida
  • Michigan
  • Illinois
  • New Mexico
  • Ohio
  • South Carolina
  • Texas
  • Utah
  • Washington
  • Wisconsin

Molina also offers Medicaid programs through the State Children’s Health Insurance Program (SCHIP) in these states. Medicaid provides insurance for low-income families.

Medicaid is the largest single healthcare payer in the US for mental health services which, include treatment for substance use disorders. An individual’s eligibility for Medicaid is determined by numerous factors, such as a person’s age, their income, the number of people in their household, if the individual has a disability, and so forth.

Individuals can enroll for Molina Medicaid by going to the Health Insurance Marketplace. Once an application is completed, it can be determined what types of programs they may qualify for.

In addition to specific state requirements, the income requirement that applies to Medicaid is based on the designation of the federal poverty level (FPL). Different states have different requirements as to what percentage of income based on the FPL is required for an individual to qualify for Medicaid coverage. Depending on the situation, individuals can have incomes that are a percentage over the FPL, and in some states, individuals with dependent children may qualify for Medicare if they make twice the FPL. The FPL levels are:

  • $11,770 for a one-person household
  • $15,930 for two-person household
  • $20,090 for three-person household
  • $24,250 for four-person household

Individuals can also use the Substance Abuse and Mental Health Care Services Administration’s Behavioral Health Treatment Services Locator to find specific providers in their state that accept Medicaid. One need not have an active Medicaid plan to be admitted to a substance use disorder treatment program. Once an individual has applied for Medicaid coverage, many programs may accept them.

Molina Medicare Programs

Molina offers Medicare Advantage healthcare plans that offer comprehensive benefits to individuals through a wide selection of health providers at very low out-of-pocket costs. Medicare is a government-funded assistance program that is available to people over the age of 65 and to some individuals who have certain types of disabilities. Individuals on Medicare do pay a monthly premium, which is based on the person’s income.

Medicare has four different parts that cover different costs.

  • Medicare Part A: This program covers the costs of inpatient treatment. Part A will typically cover up to 60 days without a coinsurance payment, but there is a deductible involved. Currently, the lifetime coverage for inpatient psychiatric treatment is 190 days; this applies to freestanding psychiatric treatment centers and not treatment in a hospital wing. Methadone treatment for opiate use disorders is covered under Part A.
  • Medicare Part B: Part B is designed to address outpatient treatment costs and typically covers up to 80 percent of approved treatments, leaving the policyholder responsible for the other 20 percent. In some cases, medications can be covered under part B.
  • Medicare Part C: Part C is an extended Medicare program that can act as a private insurance program and will incur extra costs.
  • Medicare Part D:Part D covers prescription medication costs but does not cover methadone treatment for opiate abuse (covered under part A).

More information can be obtained at Medicare’s website.

Molina Dual Medicaid/Medicare

Individuals who are disabled or over 65 and have low incomes can qualify for both Medicaid and Medicare programs.

What Determines the Amount of Coverage?

There are always determining factors on whether or not treatment for substance use disorders is covered even under government assistance programs. These considerations include whether or not the facility participates with the insurance program in question. Facilities that do not accept certain types of insurance, such as government-assisted insurance programs, should not be considered for use by individuals who have these policies.
In addition, the services in question need to be determined as medically necessary in order for coverage to be considered. Finally, the referral should have a specific treatment plan in place. This is often completed by a physician, intake personnel, and/or other personnel. Many insurance companies will not consider covering treatment for substance use disorders unless there is a concrete treatment plan. This particularly applies to coverage for inpatient, residential, partial hospitalization, and intensive outpatient treatment programs.

Molina reports that it offers a wide variety of behavioral healthcare services for its members. One of the best ways to proceed is to contact a case manager at Molina Healthcare who will get all the needed information and assist in finding the provider that will best suit the individual’s needs. In addition, case managers can help to arrange transportation to the facility and deal with any other special needs. Inpatient admissions require a precertification, and a case manager can make the precertification process run smoothly.