Medicare covers substance abuse treatment if a person’s doctor believes it is medically necessary, and if the services come from a Medicare-approved healthcare provider.
The Medicare coverage for substance abuse is broad, as it includes a screening program and most medications, as well as inpatient and outpatient treatment.
Both original Medicare, which is parts A and B, and Medicare Advantage provide coverage. However, a person who receives treatment must pay deductibles, copayments, and coinsurance.
This article discusses coverage for substance abuse treatment within each part of Medicare, along with out-of-pocket costs. It then looks at three interventions that Medicare includes in its coverage.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
All parts of Medicare provide some coverage for substance use disorders.
Parts A and B
Original Medicare comprises Part A, inpatient insurance, and Part B, outpatient medical insurance.
If a person with substance use disorder needs inpatient treatment in a general or psychiatric hospital, Part A covers the care.
When an individual needs outpatient treatment, Part B provides coverage.
Part B coverage may include:
- a screening
- individual or group psychotherapy
- psychiatric assessment
- ongoing tests
- family counseling that relates to a treatment plan
- medication management
- a select few prescription drugs that meet certain criteria
- diagnostic tests
- partial hospitalization
Part C
Part C, also known as Medicare Advantage, is the alternative to original Medicare.
It covers parts A and B benefits for the treatment of substance use disorder, but a person with a plan may need to use in-network providers.
Medigap
Medigap is a Medicare supplement insurance. Private insurance companies administer the plans.
Medigap policies help pay parts A and B out-of-pocket costs, including deductibles, copays, and coinsurance.
Policies are available to a person with original Medicare only.
Part D provides prescription drug coverage, which a person with original Medicare may purchase.
The plans include coverage of medications that doctors consider medically necessary for the treatment of opioid dependence.
Transition policy
Medicare requires Part D plans to have a transition policy.
If a person has recently signed up for a Part D prescription drug plan, there can sometimes be a delay in coverage while the new policy takes over.
If a person has an opioid dependence, the transition policy allows them to get their prescribed drugs quickly and without delay.
Methadone
Some medications, such as methadone, are not eligible for coverage under Part D.
Part D covers methadone when used as pain relief, but it does not cover the drug when it is for the treatment of opioid dependence.
During a hospital stay, Part A covers the medication a doctor prescribes.
Medicare may approve the use of methadone when prescribed in an inpatient setting.
While Medicare offers broad coverage, it does not cover every service, such as:
- private duty nursing
- support groups for substance use disorder
- transportation to mental health care services
Part A out-of-pocket costs include:
- 20% coinsurance for mental health services received in a hospital
- $1,408 deductible for each benefit period
- 0% hospitalization coinsurance for the first 60 days of each benefit period
- $352 hospitalization coinsurance for day 61–90 of each benefit period
- $704 hospitalization coinsurance for day 91 and beyond
A benefit period starts the day a person enters the hospital and ends the day after someone has been home from the hospital for 60 consecutive days.
Part B out-of-pocket costs include:
- $144.60 monthly premium
- $198 annual deductible
- 20% coinsurance
If a person is enrolled in the partial hospitalization program, they may have to pay an additional coinsurance to the hospital.
Parts C and D out-of-pocket costs vary among plans.
In outpatient settings, Medicare covers a program called Screening, Brief Intervention, and Referral to Treatment (SBIRT).
This is an early intervention approach that aims to prevent a person with non-dependent substance use from developing a substance use disorder.
The SBIRT program has the following components:
- screening for risky substance use
- a brief intervention to increase a person’s awareness of their substance use and to encourage a change in behavior
- referral for additional treatment, if needed
Beginning January 1, 2020, original Medicare and Medicare Advantage cover treatment programs for people with opioid use disorder. The coverage includes:
- FDA-approved medications for the disorder
- counseling
- individual or group therapy
- intake activities
- toxicology testing
- periodic evaluations
If a person has original Medicare, this program is free, except for the Part B deductible of $198.
Individuals with a Medicare Advantage plan may have to pay a copayment, and it would be useful to ensure that opioid treatment provider is enrolled in Medicare.
Medicare covers partial hospitalization, which is a form of treatment for substance use disorder. It sometimes serves as an alternative to inpatient care.
The treatment consists of intense outpatient psychiatric sessions that a person receives during the daytime.
The program does not require overnight stay.
Services that someone may have during partial hospitalization include:
- psychotherapy
- occupational therapy
- self-administered prescribed medication
- personalized activity therapy
- family counseling
Once someone starts to engage in substance use, Medicare covers SBIRT, which is a screening and prevention program.
After a person receives a diagnosis of a substance use disorder, Medicare covers both inpatient and outpatient medically necessary substance abuse treatment. This includes most prescription drugs.
People have two options for Medicare coverage. One is original Medicare, which is parts A and B.
If an individual has coverage through this program, they may wish to buy a Part D plan to ensure that outpatient prescribed drugs are covered.
The other coverage option is a Medicare Advantage plan, which provides parts A and B benefits, and usually includes the Part D medication coverage.