Alcohol misuse refers to drinking habits that are unhealthy but do not yet meet the medical requirements for alcohol dependency. Screening and counseling may help identify, manage, and treat alcohol misuse.
Eligibility
Medicare Part B Part B, also known as medical insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, hospital outpatient care, durable medical equipment (DME), laboratory tests, x-rays, mental health services, and some home health care and ambulance services. covers an annual alcohol misuse screening. You do not need to show signs or symptoms of alcohol abuse to qualify for this screening. However, Medicare only covers counseling afterwards if your primary care provider (PCP) The primary care provider (PCP) is the doctor or other health care worker who manages your health care and gives you a referral to consult a specialist if you need it. In Medicare Advantage, many Health Maintenance Organizations (HMOs) require you to select a PCP and get their permission or referral before seeing a specialist. Preferred Provider Organizations (PPOs) and Private Fee-for-Service (PFFS) plans do not have this requirement. determines you are misusing alcohol, meaning you are:
- A woman under age 65 who has more than three drinks at a time or seven drinks per week
- A man under age 65 who has more than four drinks at a time or 14 drinks per week
- An individual age 65+ who has more than three drinks at a time or seven drinks per week
If your PCP determines that you are eligible, Medicare will pay for up to four brief counseling sessions every year. To qualify for Medicare coverage of these counseling sessions, you must be:
- Considered mentally competent at the time counseling is provided
- Be counseled in a primary care setting (a doctor’s office or a clinic)
- Be counseled by your PCP (a doctor or a nurse practitioner)
Be aware that Medicare will not cover alcohol misuse screenings or counseling received while in an emergency room or during an inpatient hospital stay.
Costs
If you qualify, 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 annual alcohol misuse screenings, as well as counseling, at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). 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). Plans are required to cover alcohol misuse screening and counseling without applying deductibles, copayments, or coinsurance when you see an in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. provider and meet Medicare’s eligibility requirements for the service.
During the course of your screening, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit.
Note: Medicare also covers inpatient and outpatient treatment for alcoholism and substance use disorder. Services for the treatment of substance use disorder and dependency are not considered preventive care, meaning you may have to pay Medicare cost-sharing.