Does Medicare Cover Addiction Rehab?

Active addiction to substances, including alcohol, is a disease. And like all diseases, it needs to be treated. For this reason, Medicare classifies addiction treatment as a medically necessary service.

In this MedicareWire article, we’ll examine how each part of Medicare covers the different aspects of addiction treatment and rehabilitation.

What Is Addiction?

A substance use disorder, commonly known as an addiction, is a condition that inhibits your ability to control your use of a substance, drug, or medication. When you experience addiction, you will continue to use that substance despite any harmful effects it does to you and you may be more willing to perform rash actions and behaviors to enable your addiction. This can affect your ability to function appropriately in daily life, causing issues in school, work, and social interaction.¹Mayoclinic.org, “Drug addiction (substance use disorder): Symptoms & causes“, Accessed December 2, 2021

When you use a substance too frequently, you develop a tolerance to the substance and require a larger amount to achieve the beneficial effect you are craving. Failing to fulfill this addiction can lead to withdrawal symptoms that severely affect your mental and physical health.¹Mayoclinic.org, “Drug addiction (substance use disorder): Symptoms & causes“, Accessed December 2, 2021

Addiction Rehabilitation

If you or a loved one are experiencing an addiction, seeking medical help and addiction rehabilitation will help lead to recovery. Addiction rehabilitation, often shortened to rehab, is often a combination of several different treatments, such as:²Mayoclinic.org, “Drug addiction (substance use disorder): Diagnosis & treatment“, Accessed December 2, 2021

• Detoxification
• Behavioral therapy
• Self-help support groups
• Medication
• Counseling on substance use

How Does Medicare Cover Rehab?

Medicare covers drug and alcohol rehabilitation for its beneficiaries. However, there are rules about the providers you can use with Medicare. Also, some types of addiction treatment are not covered by Medicare. Certain conditions must be met before Medicare will cover treatment:³Medicare.gov, “Medicare & Your Mental Health Benefits“, Accessed December 2, 2021

1. Your provider must deem that the services are medically necessary.
2. You must receive care at a Medicare-approved facility or from a Medicare-approved provider.
3. Your provider must set up a plan of care.

In some cases, 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. Like all other services Medicare covers, the SBIRT services must be deemed medically necessary.⁴CMS.gov, “Screening, Brief Intervention, & Referral to Treatment (SBIRT) Services“, Accessed December 2, 2021

Medicare Part A – Inpatient Rehab

If you require addiction rehab in an inpatient rehabilitation facility (also known as an inpatient rehab facility, IRF, acute care hospital, or rehabilitation hospital), Medicare Part A will provide coverage for the service. Your doctor will have to verify that your condition requires this level of continual supervision and coordinated care to facilitate your rehabilitation. Rehabilitation facility services covered by Part A include:⁵Medicare.gov, “Inpatient rehabilitation care“, Accessed December 2, 2021

• Rehabilitation services, such as physical therapy, occupational therapy, and speech-language pathology
• A semi-private room
• Meal services
• Nursing services
• Medically necessary drugs
• Other necessary hospital services and supplies

If you are receiving addiction rehab care in a psychiatric hospital (rather than a general hospital), Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime.³Medicare.gov, “Medicare & Your Mental Health Benefits“, Accessed December 2, 2021

While you are in an inpatient care facility, Medicare Part A will not cover these services:³Medicare.gov, “Medicare & Your Mental Health Benefits“, Accessed December 2, 2021

• Private duty nursing
• A phone or television in your room
• Personal items, like toothpaste, socks, or razors
• A private room, unless medically necessary

Medicare Part B – Outpatient Rehab

Many health care services for substance misuse and addiction rehab are covered by Medicare Part B. This includes outpatient rehab services such as:⁶Medicare.gov, “Mental health care (outpatient)“, Accessed December 2, 2021

• Individual and group psychotherapy with licensed professionals
• Alcohol and drug misuse screening (once per year)
• Psychiatric evaluation
• Prescription drugs that require a doctor to administer them
• Mental health care (partial hospitalization)
• Outpatient hospital services (observation, lab work, durable medical equipment)

Medicare Part B will not cover the following services for your addiction rehab:³Medicare.gov, “Medicare & Your Mental Health Benefits“, Accessed December 2, 2021

• Meals.
• Transportation services to or from a mental health care service.
• Activity therapy for recreation or distraction from other issues.
• Support groups for discussion and socialization. (Note: Not the same as group psychotherapy, a Medicare-approved service.)
• Testing or training for job skills that aren’t part of your rehabilitation.

Medicare Advantage – Part C

Medicare Advantage Plans are required to provide coverage for the same services as Medicare Part A and Part B (Original Medicare). This means that your Medicare Advantage Plan will cover your addiction rehabilitation. Some plans also offer prescription drug coverage as part of being a member of their particular plan, which can help cover your doctor prescribed medications for treating addiction.⁷Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 2, 2021

However, Medicare Advantage members will be required to use services, facilities, and providers within their plan’s network. Your out-of-pocket costs after Medicare Advantage has paid their share may differ from Original Medicare’s out-of-pocket costs.⁷Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 2, 2021

Medicare Part D

If you require prescription medication as part of your addiction rehab, it will usually be covered by your Medicare Part D plan. Depending on your Part D plan, you may have to pay an annual deductible before the Part D begins paying its share, as well as a copayment per prescription.⁸Medicare.gov, “What Medicare Part D drug plans cover“, Accessed December 2, 2021

Medigap

Even after Original Medicare provides coverage for your rehabilitation, it can be difficult to handle the out-of-pocket costs that remain. Thankfully Medicare supplement insurances (Medigap) are available for purchase by private insurance companies. A Medigap policy will cover some or all of the out-of-pocket costs for Medicare-approved services, including rehabilitation services. These costs include:⁹Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed December 2, 2021

• Deductibles
• Coinsurance
• Copayments

Summary

Fortunately, Medicare does provide coverage for many addiction rehab services. We hope that this article has helped you understand how the different parts of Medicare cover the different forms of treatment for substance use disorder.

If you or someone you love is living with addiction, it is important to receive rehabilitation treatment as soon as possible. If you need help finding a rehab center or a provider that accepts Medicare in your area, you can search your local services here.

Citations

• 1
  Mayoclinic.org, “Drug addiction (substance use disorder): Symptoms & causes“, Accessed December 2, 2021
• 2
  Mayoclinic.org, “Drug addiction (substance use disorder): Diagnosis & treatment“, Accessed December 2, 2021
• 3
  Medicare.gov, “Medicare & Your Mental Health Benefits“, Accessed December 2, 2021
• 4
  CMS.gov, “Screening, Brief Intervention, & Referral to Treatment (SBIRT) Services“, Accessed December 2, 2021
• 5
  Medicare.gov, “Inpatient rehabilitation care“, Accessed December 2, 2021
• 6
  Medicare.gov, “Mental health care (outpatient)“, Accessed December 2, 2021
• 7
  Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 2, 2021
• 8
  Medicare.gov, “What Medicare Part D drug plans cover“, Accessed December 2, 2021
• 9
  Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed December 2, 2021