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 necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. service.
In this MedicareWireMedicareWire is a Medicare insurance consulting agency. We founded MedicareWire after seeing and hearing how confusing and frustrating it is to find, understand, and choose a plan. Our services are free to the consumer. article, we’ll examine how each part of Medicare covers the different aspects of addiction treatment and rehabilitation.
- Substance use disorder, also known as addiction, is when you are unable to control your use of a harmful substance.
- Addiction rehabilitation can help you recover from withdrawal symptoms and manage addictive behaviors.
- Medicare will cover addiction rehab if your doctor determines it is medically necessary.
- Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. will cover inpatient rehabilitation facilities when required.
- Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. provides coverage for counseling, screening, and outpatient facility services for addiction rehab.
- Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). will cover the same addiction rehab services as Part A and Part B, but you will be restricted to in-networkDoctors, hospitals, pharmacies, and other healthcare providers that agree to health plan members' services and supplies at a set price are in-network providers. With some health plans, your care is only covered if you get... providers.
- Most prescription drugs needed for rehabilitation will be covered by a Part D plan.
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
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
- Behavioral therapy
- Self-help support groups
- 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
- 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.
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 careInpatient care refers to care provided in a hospital or other inpatient facility. Inpatients are admitted and stay at least one night depending on their condition. 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 equipmentDurable medical equipment (DME) is equipment that is designed to last and can be used repeatedly. It is suitable for home use and includes wheelchairs, oxygen equipment, and hospital beds.)
Medicare Part B will not cover the following services for your addiction rehab:3Medicare.gov, “Medicare & Your Mental Health Benefits“, Accessed December 2, 2021
- 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 MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage.). 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 costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. 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 DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... 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
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 (MedigapMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage.) 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
- DeductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.
- CoinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service.
- CopaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.
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.
- 1Mayoclinic.org, “Drug addiction (substance use disorder): Symptoms & causes“, Accessed December 2, 2021
- 2Mayoclinic.org, “Drug addiction (substance use disorder): Diagnosis & treatment“, Accessed December 2, 2021
- 3Medicare.gov, “Medicare & Your Mental Health Benefits“, Accessed December 2, 2021
- 4CMS.gov, “Screening, Brief Intervention, & Referral to Treatment (SBIRT) Services“, Accessed December 2, 2021
- 5Medicare.gov, “Inpatient rehabilitation care“, Accessed December 2, 2021
- 6Medicare.gov, “Mental health care (outpatient)“, Accessed December 2, 2021
- 7Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 2, 2021
- 8Medicare.gov, “What Medicare Part D drug plans cover“, Accessed December 2, 2021
- 9Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed December 2, 2021