Treatment for alcoholism and substance use disorder

Medicare covers alcoholism and substance use disorder treatment in both inpatient inpatient An inpatient is a patient who has been formally admitted into the hospital by a doctor. Most inpatient care is covered under Medicare Part A (hospital insurance). and outpatient outpatient An outpatient is a patient who has not been formally admitted into the hospital as an inpatient. Most outpatient care is covered under Medicare Part B (medical insurance). settings if:

• Your provider states that the services are medically necessary
• You receive services from a Medicare-approved provider or facility
• And, your provider sets up your plan of care plan of care A plan of care is a doctor’s written plan describing the type and frequency of health services a particular patient needs.

Covered services include but are not limited to:

• Patient education regarding diagnosis and treatment
• Psychotherapy
• Post-hospitalization follow-up
• Opioid treatment program (OTP) services (see below)
  • Food and Drug Administration (FDA)-approved opioid treatment medications (methadone, buprenorphine, naltrexone)
    • Dispensing and administering drug, if applicable
  • Substance use counseling
  • Individual and group therapy
  • Toxicology testing
  • Intake activities and periodic assessments
• Prescription drugs administered during a hospital stay or injected at a doctor’s office
  • Methadone may be covered in inpatient hospital settings
• Outpatient prescription drugs covered by Part D
  • Part D plans must cover medically necessary drugs to treat substance use disorder
    • Note: Part D plans cannot cover methadone or similarly administered medications to treat substance use disorder, but they can cover methadone for other conditions, such as pain. (Note: OTPs can provide methadone for substance use disorder treatment.)
• Structured Assessment and Brief Intervention (SBIRT) services provided in a doctor’s office or outpatient hospital. SBIRT is covered by Medicare when individual shows signs of substance use disorder or dependency. SBIRT treatment involves:
  • Screening: Assessment to determine the severity of substance use and identify the appropriate level of treatment.
  • Brief intervention: Engagement to provide advice, increase awareness, and motivate individual to make behavioral changes.
  • Referral Referral Referrals are authorizations that Medicare Advantage Plans usually require for services not provided by your primary care provider (PCP). For example, Health Maintenance Organizations (HMOs) generally require you to get a referral from your PCP in order to see a specialist or get an eye exam. to treatment: If individual is identified as having additional treatment needs, provides them with more treatment and access to specialty care.

Inpatient care

Part A should cover your care if you are hospitalized and need substance use disorder treatment. Your plan’s cost-sharing rules for an inpatient hospital stay should apply.

Note: If you are receiving care at an inpatient psychiatric hospital, keep in mind that Medicare only covers a total of 190 lifetime days.

Outpatient care

Part B should cover outpatient substance use disorder care you receive from a clinic, hospital outpatient department, or opioid treatment program. Note that some substance use disorder treatment can also be provided using technology services, sometimes called telehealth.

Original Medicare Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. covers mental health services, including treatment for alcoholism and substance use disorder, at 80% of the Medicare-approved amount. As long as you receive the service from a participating provider, you will pay a 20% coinsurance after you meet your Part B deductible. If you are enrolled in a Medicare Advantage Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plan, contact your plan for cost and coverage information for substance use disorder treatment. Your plan’s deductibles and copayments/coinsurance may apply.

Drug coverage

Some medications used to treat substance use do not meet certain requirements for coverage under Medicare Part D. These medications are generally not covered by Part D or Part B. These medications can be covered by Part A during an inpatient stay or by Part B as part of medication-assisted treatment (MAT) at an OTP.

Opioid treatment programs

Medicare Part B covers opioid use disorder (OUD) treatment received at opioid treatment programs. OTPs, which are also known as methadone clinics, are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) to provide methadone as part of medication-assisted treatment. OTPs are the only place where you can receive methadone to treat opioid use disorder.

To receive Medicare coverage for OTP services, your OTP must:

• Be certified by SAMHSA
• Enroll in the Medicare program