Medicare is a publicly funded program covering many aspects of healthcare for United States citizens who are 65 and older, young individuals with certain disabilities, and individuals with end-stage kidney disease requiring transplant or dialysis. The original Medicare program offered two parts: Part A, which covered inpatient or hospitalization, and Part B, which covered other necessary health care options through an insurance program. There are also two other parts to modern Medicare: Part C, also called Medicare Advantage Plans, which are private insurance companies that are approved to work with Medicare, and Part D, which covers prescription medication.
Since Medicare is geared toward specific demographics, the overall focus of the program is not specifically on mental, behavioral, or substance abuse treatment; however, the parts in Medicare can be used to cover mental health and substance abuse treatment programs.
What Are the Treatment Levels?
When you’re worried about your patterns around drugs or alcohol, you may consider addiction treatment. If you have Medicare, you can use the parts of the program to cover some aspects of your treatment in different ways. Some of this will depend on where your treatment needs fall on the Continuum of Care, which has been defined by the American Society of Addiction Medicine (ASAM).
- Level 0.5, Early Intervention: This level covers education and prevention programs for people who are at risk of developing an addiction. For people who are covered by Medicare, this may look like a discussion between you and your physician before you take a new prescription medication, so you can work together to reduce the risk of abusing that drug.
- Level 1, Outpatient Treatment: Generally, this represents nine hours or less per week of recovery or counseling services. Outpatient rehabilitation programs, for example, meet for an hour or two per day, with flexible scheduling for day or evening availability. If you need outpatient rehabilitation services, you may only need to go two or three days per week. Medicare may cover some options of care at this level.
- Level 2, Intensive Outpatient and Partial Hospitalization: Intensive outpatient programs (IOPs) involve more than nine hours of counseling or treatment per week, with less scheduling flexibility. Partial hospitalization involves 5-6 hours a day for 5 days a week for a few days to a couple weeks followed by stepping down to an intensive outpatient treatment program.
- Level 3, Inpatient Treatment: This level involves staying in a facility for one to three months, spending most of the day focusing on approaches to behavioral therapy and recovery. Inpatient treatment is important for people who cannot stay away from substances in their current home environment or whose home environment is too unstable to support their recovery.
- Level 4, Medically Managed Intensive Inpatient Services: This level of inpatient treatment is not just for people who need to leave their home environment but also for individuals who have been physically harmed by abusing drugs or alcohol for a long time. They need consistent access to nursing care, prescription medications, and other medical interventions for a long time to remain physically stable while also going through addiction counseling.
Which Parts of the Medicare Program Can Help With Drug Rehab?
The three parts of Medicare that are directly funded by the federal government are Parts A, B, and D. These programs can be used to cover addiction treatment. Part A: This part of the Medicare program covers hospitalization, so if you are hospitalized due to mental health or substance abuse, Part A manages those costs. This includes your hospital room, meals, nursing care, and related supplies and services. Part A does not cover some parts of inpatient hospitalization, such as:
- Private duty nursing
- A private room, unless there is a medically necessary reason
- Personal items, including toothpaste, socks, or razors
- Phones or televisions in the room
The first 60 days (two months) of hospitalization have $0 coinsurance per day, days 61 to 90 have a $335 coinsurance cost per day, and day 91 and beyond have a $670 coinsurance cost per day. Part B: This part can be applied to outpatient treatment services, like appointments with physicians, therapists, and social workers. Since these medical professionals are core people in addiction treatment, Part B can help you cover the cost of these visits when you are going through addiction treatment. Specific outpatient services may be covered by Part B.
- Clinical psychologists
- Clinical social workers
- Nurse specialists and practitioners
- Physicians’ assistants
Other treatment approaches may be covered by Part B:
- Annual depression screening, as mental health is associated with a higher risk of substance abuse
- Alcohol misuse screening and counseling
- Smoking and tobacco misuse screening and counseling
- Individual psychotherapy
- Family counseling
- Other psychiatric evaluations
- Assistance managing prescriptions
- Certain drugs that are not self-administered
- Diagnostic tests
- Other physician visits
Part B may cover partial hospitalization, especially when Part A does not cover this approach to inpatient treatment. This part manages outpatient or partial-outpatient options as treatment alternatives to living in a facility, especially when that facility is a hospital. Along with some of the outpatient program, Medicare may also cover:
- Occupational therapy relevant to mental health or substance abuse treatment
- Training and education programs about your specific condition
Medicare Part B will not cover the following:
- Meals in the program
- Transportation to and from mental health services
- Support groups focused on socialization (though psychotherapy can be covered)
- Training or testing for occupational therapy or job skills that are not involved in your mental health or substance abuse treatment
This part of the Medicare program is more likely to have copayments associated with it. For example, if a therapist approves the use of your Medicare coverage for their outpatient treatment, you will still pay a percentage of this treatment. The standard Part B premium is $134 as of 2018, and the deductible and coinsurance are $183 per year. After the deductible is met, you will pay 20 percent of the approved amount.
Part D: Prescription medications are covered by Part D, and this can include psychiatric medications for depression or anxiety, some medication-assisted treatments like buprenorphine (but not methadone), and drugs used to treat chronic conditions from long-term substance abuse. The cost of Part D varies based on monthly premiums.
Although methadone is one of the most used approaches to tapering off long-term opioid abuse, Medicare does not cover this option, although an estimated 300,000 Medicare patients have been diagnosed with an addiction to opioid narcotics. However, Part D may cover buprenorphine, which can be administered by a trained physician for outpatient detox use.
You may also be able to apply Part C to substance abuse and addiction treatment programs, but Part C is private insurance, so your coverage will vary based on which Medicare-approved private insurer you work with.
Consistent Drug Addiction Treatment
Because Medicare is a federal program, there is little difference by state. The “original” Medicare parts, A and B, are the same across all 50 states in the U.S. Part D may vary across state lines, based on how the local and state governments regulate pharmacies. You should receive good coverage for your treatment no matter where you live. If you are concerned about how Medicare can help you, don’t forget, social workers are covered by Part B. Your questions can be answered in that appointment.