Drug Treatment Centers and Medicare Coverage
Can I use Medicare to pay for drug treatment?
Medicare can be used to cover the cost of drug and alcohol rehabilitation. But there are rules about the providers people can use with Medicare, and some types of addiction treatment are not covered by Medicare at all. It is a good idea to contact the Medicare organization directly to find more detailed information.
You may be eligible for Medicare if:1
- You are age 65 or older.
- You are younger than 65 and have a disability.
- You are younger than 65 and have end stage renal disease (permanent kidney failure that requires dialysis or a transplant).
For individuals with low incomes, Medicaid may be able to supplement Medicare coverage. It can help with coinsurance and mental health services that Medicare does not cover.2
Of course, navigating Medicare can be confusing. The following information covers the basics of using Medicare to access drug treatment.
Using Medicare to Cover Drug and Alcohol Addiction Treatment
The short answer is that Medicare can cover drug and alcohol rehabilitation treatment. However, certain conditions must be met for Medicare to provide coverage:3
- Your provider must deem that the services are medically necessary.
- You must receive care at a Medicare-approved facility or from a Medicare-approved provider.
- Your provider must set up a plan of care.
MedicareInteractive.org offers the following breakdown of services:3
- Part A helps with payment for inpatient treatment at a hospital or inpatient rehab center.
- Part B helps with payment for outpatient treatment services through a clinic or a hospital outpatient center.
- Part D can be used to help pay for drugs that are medically necessary to treat substance use disorders.
- Medicare also covers Screening, Brief Intervention, and Referral to Treatment (SBIRT) services provided in a doctor’s office.
Medicare Part A Provisions for Inpatient Treatment
Medicare Part A is generally considered to be hospital insurance. Its main areas of coverage are:4
- Hospital inpatient care.
- Care at skilled nursing facilities.
- Inpatient care at a skilled nursing facility (that’s not custodial or long-term care).
- Home health care.
Part A will cover inpatient care for a substance abuse disorder if the services are determined to be reasonable and necessary.5
Under Part A, an individual can complete no more than 190 days total treatment from a specialty psychiatric hospital. This is the lifetime limit. Care from an inpatient hospital includes care received at:6
- Acute care hospitals.
- Critical access hospitals.
- Inpatient rehab centers.
- Long-term care hospitals.
- Inpatient care as part of a qualifying research study.
- Mental health care.
An inpatient drug and alcohol rehabilitation program, combined with follow-up care and support, can support a person struggling with addiction to attain long-term recovery. Inpatient program services can include detox, individual therapy, group therapy, addiction education, relapse prevention, 12-step meetings, recreational activities, and aftercare planning.
Medicare Part B Provisions for Outpatient Treatment
Part B provides care for outpatient treatment of drug and alcohol rehabilitation.3 As opposed to inpatient care, these programs don’t require residence in the facility during treatment.
Part B also covers partial hospitalization (PHP), which is an outpatient treatment program provided through a hospital or a mental health center.5 A PHP will provide a more intensive program than standard outpatient treatment but still doesn’t require being checked in to a hospital.
A physician must certify that individuals in partial hospitalization require that form of treatment, and the person’s plan of care must include at least 20 hours of treatment per week.5
Services offered in partial hospitalization programs include:5
- Individual and group therapy.
- Occupational therapy.
- Family therapy.
- Patient education.
- Activity therapies that are not chiefly recreational.
- Drugs that cannot be self-administered and are for therapeutic reasons.
- Medically necessary diagnostic services for mental health.
Part B also covers an alcohol misuse assessment once per year if you’re an adult who drinks but doesn’t meet the criteria for an alcohol use disorder. If through this assessment your provider determines that your level alcohol use is potentially problematic, you may be able to receive up to 4 face-to-face counseling sessions per year.7
SBIRT and Alcohol Risk Screening and Counseling
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a screening and intervention technique that can help identify individuals at risk of experiencing alcohol related health issues prior to the need for more comprehensive substance abuse treatment. This type of intervention can be covered by Medicare as a preventive measure when someone in a primary care setting shows signs of substance abuse.5
The process includes:5
- A screening to assess whether the person has risky substance use behaviors.
- A brief intervention in which the provider has a conversation with the person about their substance abuse and offers feedback and advice.
- Referral to services, therapy, or treatment for people whose screening suggests a need for further services.
Part D Coverage for Medication
Medicare D may cover medications used in treating substance use disorders, including drugs for opioid dependence, such as Suboxone. Methadone is not a Part D drug when used for the treatment of opioid dependence because it cannot be distributed at a retail pharmacy. However, it can be prescribed for pain.3,5
Medicare drug programs might not cover all drugs, but they are required to cover antidepressant, anticonvulsant, and antipsychotic medications used during mental health treatment.8
Each specific drug plan under Part D has its own listing of medications that can be covered by the plan—also known as its formulary—so it’s best to make sure that the medications are on the specified formulary of your plan.8
Getting More Help
It’s a good idea to contact Medicare directly to get more detailed information and verify the services that can be covered. If you’re a family member or caregiver who is helping to manage treatment for someone covered by Medicare and need their personal information to help with care, have them fill out the Medicare Authorization to Disclose Personal Health Information.
More information and listings of local treatment centers that may accept Medicare can be obtained through the Substance Abuse and Mental Health Services Administration (SAMHSA).
. U.S. Department of Health and Human Services. (2014). Who is eligible for Medicare?
. Center for Medicare Advocacy. Medicare Coverage of Mental Health and Substance Abuse Services.
. Medicare Interactive. Treatment for alcoholism and substance use disorder.
. Medicare.gov. What Part A covers.
. Centers for Medicare & Medicaid Services. (2016). Medicare Coverage of Substance Abuse Services.
. Medicare.gov. Your Medicare Coverage.
. Medicare.gov. Alcohol misuse screenings & counseling.
. Centers for Medicare & Medicaid Services. (2017). Medicare & Your Mental Health Benefits.
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