Medicare coverage of treatment for alcoholism and drug abuse

Section IV.l. Mental Health Services
Question 4 of 4 (use "Last" or "Next" buttons to see more)

Medicare will help pay for treatment of alcoholism and drug abuse in both inpatient and outpatient settings if:

  • You receive services from a Medicare-participating provider or facility;
  • Your doctor states that the services are medically necessary; and
  • Your doctor sets up your plan of treatment.

Inpatient care:

Medicare Part A helps pay for your care if you are hospitalized for substance abuse treatment. Your out-of-pocket costs are the same as for any other type of hospital stay.

Note:  Medicare only covers a total of 190 days spent in a psychiatric hospital for an entire lifetime. If someone reaches that limit, Medicare may cover further inpatient mental health care in a general hospital but not a psychiatric hospital. This rule only applies to free-standing psychiatric facilities that are not considered a part of general hospitals.  

Outpatient care:

Medicare Part B helps pay for outpatient substance abuse treatment services from a clinic or hospital outpatient department.

Beginning in 2014, Medicare will pay 80 percent of its approved amount for mental health services, and you or your supplemental insurance are responsible for the remaining 20 percent. 

Covered services include, but are not limited to:

  • Psychotherapy
  • Patient education regarding diagnosis and treatment
  • Post-hospitalization follow-up
  • Prescription drugs administered during a hospital stay or injected at a doctor’s office
    • Methadone may be covered if provided to hospital inpatients but not provided in outpatient clinics. 
  • Outpatient prescription drugs covered under Part D
    • Part D plans must cover medically necessary drugs to treat drug abuse either through a formulary (list of covered drugs) or through the exception process
    • Note: plans cannot cover methadone to treat substance abuse, but can cover methadone for other conditions, such as pain. 
  • Structured Assessment and Brief Intervention (SBIRT) services provided in a doctor’s office or outpatient hospital department. SBIRT is covered by Medicare when patients show signs of drug abuse or dependency. This is a public health approach to treat substance abuse that involves:
    • Assessment to quickly determine the severity of substance use and identify the appropriate level of treatment.
    • o Brief intervention or advice focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. Referral to treatment provides those identified as needing more extensive treatment with access to specialty care.
  • Medicare covers a new preventive benefit that offers screening and counseling for people who show signs of alcohol misuse but are not alcohol dependent and do not necessarily show signs of abuse. Click here to learn more about this benefit.

The costs and coverage above reflect Original Medicare coverage of alcoholism and substance abuse treatment. Know that Medicare Advantage plans must cover the same services as Original Medicare; however, your plan will likely require you to see an in-network mental health care provider. If you have a Medicare Advantage plan, contact your plan to see what your copayments are for seeing an in-network mental health provider.

 


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