Medicare covers substance abuse rehabilitation services, ranging from screenings to inpatient rehab and everything in between. Furthermore, the service you need will determine which part of Medicare will cover it. Below we’ll discuss all you need to know about Medicare rehab coverage for substance abuse.

The National Institute on Drug Abuse found that almost a million Americans over 65 currently live with a substance abuse disorder. Over the past ten years, the number of people in that age range seeking help has doubled. Substance abuse is a problematic health concern to overcome.

Many will struggle throughout life. However, there is help, and you’re not alone. There are many treatments and rehab options of which you can take advantage. Don’t try and fight this demon alone.

Medicare-Approved Treatments for Substance Abuse and Rehab

Regarding alcohol or substance abuse, Medicare’s coverage could fall under an inpatient or outpatient situation. Before treatment is covered, your doctor must certify certain items.

  • The services must be medically necessary.
  • The facility must be medicare-certified.
  • Your healthcare provider must set up a plan of care.

Medicare will provide coverage for substance abuse and rehab if all these items line up. There are many covered services for Medicare beneficiaries with substance abuse problems. The services listed below are some of the included treatments and rehabilitation options.

  • Patient education about treatment and diagnosis
  • Post-hospitalization follow-up
  • Prescription drugs given during a hospital stay or injections performed at a doctor’s office
    • Methadone may be covered if administered in an inpatient hospital settings
  • Psychotherapy
  • Opioid treatment program services (OTP)
    • FDA-approved opioid treatment medications
      • Methadone
      • Buprenorphine
      • Naltrexone
        • If Applicable, administering and dispensing drugs
  • Substance abuse counseling
  • Individual and group therapy
  • Toxicology Tests
  • Intake and periodic assessments
  • Outpatient prescription drugs
    • Part D plans must cover medically necessary drugs to treat substance use disorder.
  • Structured Assessment and Brief Intervention services occur in a doctor’s office or outpatient hospital. SBIRT is covered by Medicare when a Medicare beneficiary shows signs of substance use disorder or dependency.
    • SBIRT treatment involves:
      • Screening
        • An assessment to determine the severity of the substance use and the correct treatment.
      • Brief intervention
        • Intervention includes engagement to administer advice, increase awareness, and motivate the beneficiary to change their behavior.
      • Referral to treatment
        • A referral is provided for further treatment and specialty care if additional treatment is necessary.

Medicare Coverage for Inpatient Care for Substance Abuse and Rehab Services

Medicare Part A covers inpatient treatment and care. With Medicare part A, you have a large deductible when admitted for each benefit period as an inpatient. Once You have been in the hospital for more than 60 days, an additional daily copay is required.

Medicare has limitations on inpatient coverage at a psychiatric hospital. Coverage is limited to 190 days in a lifetime in these specialized hospital facilities.

Medicare Coverage Outpatient Care for Substance Abuse and Rehab

Medicare Part B covers treatment services in an outpatient rehab center and screenings. Once you meet the small annual Medicare Part B deductible, you’re responsible for a 20% coinsurance and, if applicable, excess charges.

Outpatient treatment options can include:

  • Addiction treatment
  • Alcohol misuse screening
  • Alcohol rehabilitation
  • Behavioral health counseling
  • Drug Rehab
  • Evaluations
  • Mental Health Care
  • Substance abuse treatment

These services typically occur at outpatient treatment centers or treatment facilities.

Medicare Supplement Coverage for Substance Abuse and Rehab

Medigap plans are secondary health insurance coverage that works with Medicare. Medicare Supplement plans help pay for your cost-share portions left after Medicare pays. Out of 12 letter plans, there are five that stand out.

Depending on your plan, you may pay as little as $0 out of pocket when you use your health insurance program for items and services covered under Original Medicare.

Medicare Advantage Coverage for Substance Abuse and Rehab

Medicare Advantage combines your Medicare Part A and Medicare Part B benefits into one plan. The benefits included with Medicare Part C will typically have your Part D prescription drug coverage and benefits not included by Original Medicare, such as dental, vision, and hearing services.

Medicare Advantage plans are required to cover the same benefits as Original Medicare but are allowed to have coverage that exceeds that of Orignal Medicare. The Medicare services through the Centers for Medicare and Medicaid Services contract private insurance companies to administer Medicare Part C plans.

These plans have vastly different costs and benefits. Working with a licensed insurance broker to review the Medicare Advantage plan’s benefits before enrolling is wise.

Medicare Part D Coverage for Substance Abuse and Rehab

Medicare Part D is the standalone prescription drug coverage. These plans work with Original Medicare and Medicare Supplements and cover prescription drugs you pick up from the pharmacy. Like the Medicare Advantage plans, private insurance companies contracted with Medicare to administer the programs.

Regarding prescription drugs for substance abuse, some medications are covered under Medicare Part B, and your Part D prescription drug plan will cover others.

What to do when your Medicare coverage runs out of rehab days

Medicare has limits on coverage for substance abuse and rehab services. If you exhaust your Medicare-covered benefits, you still have a few options to help you.

Substance Abuse and Mental Health Services Administration – SAMHSA is a program under the Department of Health and Human Services. They provide grants and programs for people that need assistance with substance abuse and mental health services.

National Alliance on Mental Illness – NAMI primarily focuses on mental health and illness. While their main focus is helping mental illness treatment and wellness, substance abuse is often tied to mental illness and symptoms. NAMI offers counseling services to assist with mental health.

FAQs

Does Medicare cover CPT H0020?

CPT H0020 is a payment code for Alcohol and drug services, methadone administration, and service. This code can be covered by Medicare if it’s medically necessary and administered by a licensed professional.

What are the requirements to be eligible for treatment under Medicare?

  • For treatment to be covered, your doctor must certify certain items.
  • The services must be medically necessary
  • The facility must be medicare-certified
  • Your healthcare provider must set up a plan of care

How to Get Help with Medicare Coverage for Substance Abuse

Beating substance abuse can be one of the most isolating and difficult situations you can go through. Let our licensed insurance agents help you make choosing the right coverage easy. We’ll help answer questions and educate you on your supplemental Medicare options.

Our agents are experts at Medicare and will go the extra mile to ensure you’ve got coverage for prescription and healthcare needs.

Let us make this part of the process simple for you. Please fill out our online request form or give us a call for assistance. Our agents are experts in Medicare and look forward to making the process painless.

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by Lindsay Malzone, Lindsay Malzone is the Medicare editor for Medigap.com. She's been contributing to many well-known publications since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.