FREQUENTLY ASKED QUESTIONS

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I am on Medi-Cal and need substance use disorder treatment. Will health care reform help me obtain it?

Until 2014, health care reform will not change many aspects of substance use disorder (SUD) treatment for those currently receiving Medi-Cal benefits. Until this time, you are entitled to substance use treatment services through Medi-Cal under a benefit known as Drug Medi-Cal (DMC). The DMC program provides five different treatment modalities. They are: (1) narcotic treatment; (2) Naltrexone for opioid dependence; (3) outpatient drug free counseling (group or individual); (4) day care rehabilitative (more frequent, longer duration counseling), and, (5) perinatal residential services.

For more information on your DMC benefit, contact your county alcohol and drug services agency.

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I am uninsured, do not qualify for Medi-Cal, and need substance use treatment. Will health care reform help me obtain it?

Depending on your income level and age, you may qualify for coverage in three ways:

  • If you are under 26 and your parents’ health plan covers children, you are most likely now eligible to remain under their coverage. Effective September 2010, under the Affordable Care Act (ACA), what is known as health care reform, adult children may join or remain on their parents plan whether or not they are:
    • married;
    • living with parents;
    • in school;
    • financially dependent; or
    • eligible to enroll in their employer’s plan, with one temporary exception: Until 2014, “grandfathered” group plans are not required to offer dependent coverage up to age 26 if a young adult is eligible for group coverage outside their parents’ plan.

If you are over age 26, and currently do not qualify for Medi-Cal, the ACA will not benefit you until January 1, 2014. At that time, the ACA will assist you in the following ways:

  • The ACA will expand eligibility in 2014 for Medi-Cal to all individuals under age 65 who earn less than 133 percent of the federal poverty level (approximately $14,000 for an individual and $29,000 for a family of four) based on modified adjusted gross income (MAGI). MAGI is a formula used by the government to adjust incomes. In most cases, by applying the MAGI formula, you may actually earn more than the incomes stated below.

    Annual Income
    Individual Family Coverage Options Cost
    Up to $14,400 Up to $29,327 Eligible for Medi-Cal. Low-income Californians who are U.S. citizens, as well as most legal immigrants, can enroll in Medi-Cal. Current copayments range from $1 to $5 for selected services. A provider may not refuse care if a patient cannot pay for the cost of a visit.
    Up to $43,320 Up to $88,000 Eligible to buy subsidized private coverage through a new health insurance exchange market. Participating insurers must offer a package of “essential” benefits that covers at least 60% of health care expenses. Buyer’s share of premium many not exceed 2% of annual income at the low end of the earning scale to 9.5% at the top. Yearly limits on out-of-pocket costs also apply.

  • People with incomes above 133 percent of the federal poverty level, who are not covered by employer-sponsored insurance, will be able to obtain coverage in 2014 through the newly created state health insurance Exchange. The Exchange essentially picks-up where Medi-Cal eligibility ends by providing premium subsidies to individuals and families with incomes between 133 percent and 400 percent of the FPL ($43,300/individual or $88,200/family of 4). Again, the health plans that participate in the Exchange must offer SUD treatment benefits at the same level they offer benefits for other medical conditions. The cost of obtaining coverage through the Exchange will be based on income. Those earning less will pay less than those with higher incomes.

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I was diagnosed with a substance use disorder and cannot obtain health insurance because of this pre-existing condition. Will health care reform help me obtain it?

Effective September 2010, those who have a pre-existing condition, and are under age 19, can enroll in their parent’s group health plan and remain a covered dependent up to age 26.

Beginning January 1, 2014, all individual adults will be able to obtain health coverage on a guaranteed issue basis. Guaranteed issue means health plans will no longer be able to deny coverage based on pre-existing medical conditions, including substance use disorders, or charge higher premiums due to existing health conditions.

However, between now and 2014, individual adults unable to obtain health coverage due to a pre-existing condition can enroll in the temporary high risk pools created by health care reform. In California, the temporary high risk pool is known as the Pre-Existing Condition Insurance Plan (PCIP), which is operated by the Managed Risk Medical Insurance Board (MRMIB).

The PCIP will cover a broad range of health benefits, including primary and specialty care such as substance use services, hospital care, and prescription drugs. All benefits are available to you, even benefits to treat a pre-existing condition(s). Premiums are based on the subscriber’s age and region of residence in California.

For more information please call 1-877-428-5060 Monday-Friday, 8 a.m. to 8 p.m. or, on Saturday, 8 a.m. to 5 p.m. or go to www.pcip.ca.gov.