image of drugs on table; medicare coverage substance abuse and rehabilitation

Medicare Coverage: Substance Abuse and Rehabilitation

Age often comes with aches and pains, and that can lead seniors to take habit-forming painkillers or opioids. In fact, Americans aged 65 and up are one of the demographics hit hardest by the opioid epidemic sweeping across the United States. If you need help treating substance abuse or alcoholism, here’s what Medicare will cover for your treatment.

Original Medicare coverage

Original Medicare (Part A and Part B) covers inpatient and outpatient substance abuse treatment and rehabilitation if you meet all of the following qualifications:

  • Your doctor deems the treatment medically necessary;
  • You receive treatment from a Medicare-approved doctor, clinic, hospital, or rehab facility; and
  • Your provider creates a plan of care for your treatment process.

Medicare-covered services include but are not limited to:

  • Patient education of diagnosis and treatment options
  • Psychotherapy
  • Post-hospitalization follow-up
  • Prescription drugs administered in an inpatient setting
  • Injectable drugs administered in a doctor’s office

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Structured Assessment and Brief Intervention coverage

Medicare also covers Structured Assessment and Brief Interventions (SBIRT). This is an assessment provided by a doctor if the doctor senses the patient may struggle with substance abuse or alcoholism.

An SBIRT involves:

  • Screenings to determine the severity of the abuse and identify an appropriate treatment plan;
  • Brief interventions in which the doctor helps the patient acknowledge the problem, provides advice, and motivates them to seek help; and
  • Referrals for treatment or specialized care.

Inpatient coverage

Part A covers your treatment if you are hospitalized for substance abuse. You will not be responsible for a coinsurance for the first 60 days, but you will be responsible for:

  • $1364 deductible for each benefit period
  • $341 daily coinsurance for days 61-90
  • $682 daily coinsurance for 60 lifetime reserve days

Note: if you receive treatment from a psychiatric hospital, Medicare will only cover a total of 190 lifetime days. In other words, you will only have 190 days of coverage the entire time you have Medicare.

Outpatient coverage

Part B covers substance abuse treatment when you receive it from a clinic or hospital outpatient department. Medicare pays 80 percent of all covered services and items, and you’re responsible for the remaining 20 percent as well as the Part B deductible.

Part D coverage

By law, Part D plans must cover outpatient drugs that treat substance abuse. However, Part D will not cover methadone for substance abuse, only for pain management.

Additional notes

  • Medicare Advantage. If you have a Medicare Advantage (Part C) plan, coverage for substance abuse may vary depending on your plan. For more information about substance abuse treatment, contact your plan directly.
  • Methadone. Methadone may be covered in inpatient hospital settings. Methadone is not covered in oral doses or when it is given in an outpatient setting.
  • Get help. Addiction is not a choice; don’t be afraid or ashamed to ask for help from a doctor or loved one. To find a rehabilitation center near you, visit the American Addiction Centers.

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