Medicare Coverage of Substance Abuse
This article was updated on: 10/21/2018
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), about 21.7 million people, or 8.1% of the population, needed substance abuse treatment in 2015. If you or someone you love is a Medicare beneficiary and needs substance abuse treatment, here’s what you need to know.
What is substance abuse?
Although the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) no longer uses the term “substance abuse,” preferring instead “substance use disorder,” the condition is generally understood to mean that someone’s use of alcohol or drugs, either prescription or illicit, impairs his or her ability to manage the responsibilities of work, school, and/or home or causes health problems or disability. The disorder is diagnosed when there is evidence of social impairment, impaired control, and risky behaviors, in addition to other criteria.
The National Institutes of Health (NIH) National Institute on Drug Abuse (NIDA) says individuals who have substance addictions may also face a variety of mental and physical illness related to their substance abuse that further complicate the treatment process.
How is substance abuse treated?
It’s important to note that there is no specific treatment that is appropriate for every individual. In general, substance abuse treatment may involve one or more of the following, according to NIDA:
- Medically assisted detoxification to manage any potential symptoms of withdrawal from the substance.
- Behavioral therapy to help the individual learn how to avoid substances and cope with cravings.
- Individual, group, and family counseling.
- Treatment with prescription medications.
Substance abuse treatment usually occurs in one of three ways:
- Inpatient care in a hospital or residential treatment facility.
- Partial hospitalization, which is an intensive outpatient program for individuals who need at least 20 hours per week of therapeutic services.
- Outpatient care in a doctor or other licensed provider’s office or outpatient facility.
Does Medicare cover substance abuse treatment?
Although there is no specific coverage for substance abuse treatment under Medicare, the program may pay for medically necessary and reasonable services to treat addiction and abuse disorders.
If your doctor or other provider recommends inpatient treatment, Part A may pay for your inpatient stay, as long as your doctor believes it is medically necessary for your condition. You are responsible for any applicable Part A deductibles and copayment or coinsurance amounts.
Medicare may also cover substance abuse treatment in a partial hospitalization program (PHP), if your doctor certifies that you need 20 or more hours of therapeutic services per week. Your doctor must develop and submit a treatment plan and recertify your need for PHP care on an ongoing basis for Medicare to continue paying for your care.
Part B may also cover outpatient substance abuse counseling under the same guidelines it uses to pay for counseling services for any other mental illness. Counseling must be provided by a credentialed health care provider who participates with Medicare, including:
- Doctor (psychiatrist or other)
- Clinical psychologist
- Nurse practitioner or physician’s assistant
- Clinical social worker
You must get counseling in the provider’s office, a hospital outpatient department, or a community mental health center. Medicare may pay 80% of the allowable charges for your counseling sessions after you’ve met your Part B deductible. There may be an extra copayment or coinsurance amount if you get treated in a hospital outpatient setting.
Does Medicare cover prescription medications for substance abuse treatment?
If you have Medicare Part D prescription drug coverage, most prescription medications for substance abuse treatment may be covered.
Medications you receive as an inpatient for substance abuse treatment may be included in your Part A coverage for those services.
In some cases, if you are given medications in an outpatient setting for treatment of substance abuse, Part B may cover them. However, they usually must be medications that are not self-administered. There may be other criteria for Part B coverage of outpatient prescription drugs used to treat substance abuse and addiction; your doctor or other health care provider will be able to advise you whether your medications are covered under Part B.
Need more information on Medicare and substance abuse treatment?
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