If you are a Medicare beneficiary, you may be wondering if Medicare covers treatment for substance use disorder. Both original Medicare and Medicare Advantage plans cover various treatment options for this condition, including inpatient care, outpatient care, and prescription drugs.
In this article, we’ll discuss Medicare coverage options for substance use disorder treatment.
If you are a Medicare beneficiary, you are covered for many of the treatment options currently available for substance use disorder. Here’s how Medicare covers you for these treatments:
- Medicare Part A covers inpatient hospital care and inpatient care in a rehabilitation facility or hospital.
- Medicare Part B covers outpatient mental health services, alcohol misuse screenings, and other behavioral health services.
- Medicare Part C covers anything already included under Medicare parts A and B, plus extras like prescription drug coverage.
- Medicare Part D covers certain prescription drugs that may be necessary in the treatment of substance use disorder.
- Medigap covers certain expenses related to your original Medicare plan, such as deductibles, copayments, and coinsurance.
Medicare Part A, or hospital insurance, covers any necessary inpatient hospitalization for substance use disorder. It also covers inpatient care in a rehabilitation facility or rehabilitation hospital.
Medicare Part A coverage includes:
- inpatient hospitalization
- inpatient drug rehabilitation services
- coordinated care from nurses and physicians
- any drugs necessary for treatment while you’re an inpatient
You qualify for inpatient rehabilitation under Medicare Part A if your doctor has certified it as a necessary treatment of your condition.
There are costs associated with inpatient hospitalization and rehabilitation services under Medicare Part A. These Part A costs include:
Medicare Part B, or medical insurance, covers outpatient mental health counseling, alcohol misuse screenings, and intensive outpatient programs for substance use disorder.
Medicare Part B coverage includes:
- psychiatric evaluations
- alcohol misuse screenings
- individual or group therapy
- certain prescription drugs
- partial hospitalization (intensive outpatient drug rehab)
- outpatient hospital services
In some instances, Medicare will also cover services related to Screening, Brief Intervention, and Referral to Treatment (SBIRT). These services are intended to help those who may be at risk of developing substance use disorder. Medicare covers SBIRT services when they are deemed medically necessary.
You qualify for these outpatient treatment services under Medicare Part B if your doctor or counselor accepts Medicare assignment. You must also have paid your Part B deductible and premiums to get coverage.
The costs for Medicare Part B include:
- Premium. This is usually $148.50 per month (although it may be higher, depending on your income).
- Deductible. In 2021, this is $203 for the year.
- Coinsurance. You may owe a certain amount for services you receive, which is usually 20 percent of the Medicare-approved cost after you’ve met your deductible.
Medicare Part D is an add-on to original Medicare that helps cover the cost of prescription drugs. This can be used to cover medications you need during treatment for substance use disorder.
Most Medicare Advantage, or Medicare Part C, plans also offer prescription drug coverage.
Drugs that may be used in the treatment of opioid, alcohol, or nicotine use disorders include:
- nicotine replacement therapies
- Chantix (varenicline)
Each prescription drug plan has its own formulary, or list of approved drugs. Drugs are arranged in tiers from the least expensive generic drugs to the more expensive brand name drugs. The drugs listed above may range in cost according to the tier and whether the drug is brand name or generic.
There are additional costs associated with adding on a Medicare Part D plan. These Part D costs include:
- Premium. This amount will vary depending on the plan you enroll in, your location, and other factors.
- Deductible. This amount will also vary depending on your plan but cannot cost more than $445 in 2021.
- Coinsurance or copayments. These will differ for each of the drugs you’re prescribed.
Medigap, or Medicare supplemental insurance, is an add-on plan that helps cover some of the costs from your other Medicare plans. If you need treatment for substance use disorder, having a Medigap plan may help cover some of your costs, such as:
- your Medicare Part A deductible and coinsurance
- your Medicare Part B deductible, premium, and coinsurance
- blood for transfusions (up to 3 pints)
- medical costs during foreign travel
To enroll in a Medigap plan, you must already be enrolled in Medicare parts A and B. You can enroll into Medigap through a private insurance company that sells plans.
Some Medicare beneficiaries are also eligible to apply for Medicaid. Medicaid is another health insurance option that helps cover Americans with lower incomes. If eligible, Medicare beneficiaries can use Medicaid to help cover treatment costs.
You can call your local Medicaid office for more information and find out if you’re eligible for coverage.
Some rehabilitation facilities offer financing options that allow you to pay for your services later, like through a payment plan. This financing can help if you need immediate substance use disorder treatment but don’t have the funds set aside to pay for it upfront.
Although much of your treatment will be covered, as described above, there are a few things that aren’t included that you should know.
Medicare Part A does not cover private nursing, a private room, or other added amenities during your inpatient hospital stay.
Medicare Part B does not cover any hospitalization or services associated with inpatient care, as these are generally covered under Medicare Part A. Any medical equipment that is not deemed medically necessary or “durable medical equipment” will also not be covered.
Parts C and D
Not all drugs are covered under Medicare Part D or Medicare Advantage plans. However, all Medicare prescription drug plans are required to cover antidepressants, antipsychotics, and anticonvulsants. If these medications are prescribed for substance use disorder, they will be covered by your drug plan.
The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition)
According to the National Association of Addiction Treatment Providers, the warning signs of substance use disorder may include:
- misusing substances
- increased physical tolerance of the substance
- neglecting relationships and responsibilities
- cravings to use the substance despite consequences
- repeated and failed attempts to quit
- tolerance to substances
- withdrawal from work, recreational, or social activities
- continued used of the substance despite worsening physical and mental health problems
- painful physical and psychological withdrawal symptoms when the effect of the substance wears off
If you think that you or someone you love is struggling with substance use disorder, there are resources that can help:
- The Substance Abuse and Mental Health Services Administration (SAMHSA) has a 24-hour helpline that can be reached at 800-662-HELP (4357).
- You can also visit SAMHSA’s website to learn more about the available programs and initiatives that can help.
If you or a loved one has substance use disorder and are enrolled in Medicare, you can rest assured that almost all of the necessary treatment will be covered by Medicare.
Inpatient hospitalization or rehabilitation stays are covered under Medicare Part A. Supportive outpatient services and programs are covered under Medicare Part B. Some prescription drugs for treatment are covered under Medicare Part D or Part C.
If you or someone you know needs help for substance use disorder, getting the proper treatment is critical. Reach out to a healthcare professional to access a treatment program near you.