Does Medicare Cover Drug Rehab?
Medicare is a federal health insurance program and it is available for the following groups of people:1
- People age 65 and older
- People under 65 who have disabilities
- People with end-stage renal disease, permanent kidney disease, on dialysis, or transplant.
There is another federal program, called Medicaid, which is the healthcare program that helps people in lower-income brackets or who have limited resources and covers children, pregnant women, and people with disabilities.2 Some states have a Health Insurance Marketplace® that has expanded the availability of insurance plans to the broader public.
If you qualify for Medicare meeting the above requirements, Medicare can cover substance abuse treatment and can cover alcohol misuse screening and counseling.3 Medicaid and state Marketplace insurance plans also cover substance use disorder treatment.
Navigating through these systems can feel daunting. To help make it easier, below you will find a guide on how to access treatment for a substance use disorder if you are covered under Medicare.
What Will Medicare Cover?
There are multiple parts to Medicare, the main ones are called Part A and Part B.
Part A is referred to as hospital insurance, and you may qualify for it if you are getting social security benefits or if you or your spouse had Medicare-covered government employment.1 You can also qualify for Part A if you have qualified for social security disability for 24 months, or have end-stage kidney disease.1
Although most people who qualify for Part A do not have to pay a premium, Part B does have a premium that is deducted from social security or other retirement checks each month. Medicare Part B helps cover medical services like doctor’s appointments and many outpatient treatments.4
Medicare Part D covers prescription drugs that may be used in your treatment plan.1
While there is no specific category for substance abuse treatment under Medicare, Medicare will cover services needed for substance abuse treatment when deemed necessary:5
- Inpatient treatment may be covered if deemed reasonable and necessary, and any professional services provided during that care including medication will also be covered.
- Outpatient rehabilitation for substance use disorder, including evaluation from a licensed clinical social worker, psychologist, or psychiatrist is covered. Intensive outpatient programs may also be covered. Although Medicare coverage will cover substance use disorder treatment services provided at rehab facilities, it does not consider the facility itself as a bundle deal. This means that you may still be responsible for direct or indirect incidentals at the facility.
- Medicare also covers Screening, Brief Intervention, and Referral to Treatment (SBIRT) services. This is an early intervention approach that was designed to help people with nondependent substance abuse disorders get the services they need before more extensive or specialized treatment becomes necessary. The goal of SBIRT is to prevent future unhealthy consequences of alcohol and drug use. The SBIRT screening may be done in the primary care setting, where a trained physician will use information about your drinking or drug use history to help guide you toward the best treatment options for you.
Medicare can also help cover partial hospitalization programs (PHPs).5 Partial hospitalization programs involve intensive outpatient psychiatric day treatment that may be a good alternative to inpatient hospitalization for some people. When admitted to a PHP, your doctor will need to certify and recertify the need for partial hospitalization of at least 20 hours per week.5 If you are enrolled in a PHP, you will participate in:5
- Psychotherapy services.
- Occupational therapy if deemed necessary.
- Services provided by other staff, like social workers and psychiatric nurses.
- Family counseling services.
- Diagnostic services related to mental health treatment to assess for co-occurring disorders.
Does Medicare Cover Mental Health Care?
Mental health disorders affect people from all walks of life and all age groups. The coexistence of a mental health disorder and a substance use disorder is known as having co-occurring disorders. People with mental health disorders are more likely to also suffer from a substance use disorder. Approximately 9.2 million Americans have co-occurring disorders.6 When experiencing co-occurring disorders, you may have diagnoses of 2 or more substance use disorders as well as mental health disorder(s). Some drugs are more commonly abused by people who are struggling with co-occurring disorders, and these include:6
- Stimulants, like amphetamine and methamphetamine.
- Prescription drugs.
Under Medicare, if you experience a mental health disorder, Medicare Part A will help cover mental health services if you need an inpatient hospital stay or if you are admitted to a psychiatric hospital.7 Then, Medicare Part B will help cover mental health visits from a doctor or other services that you may need after you are released from your inpatient stay.7Under Part B, the following services related to mental health care are covered:7
- A depression screening and an alcohol misuse screening each year
- Individual or group psychotherapy
- Family counseling
- Psychiatric evaluations
- Medication management
- Prescription drugs
- Individual and group therapy
How Long Does Medicare Cover Rehab?
Treatment for substance abuse is designed to help people experiencing addiction by helping them to stop using drugs and return to productive, functioning lives. Most people that get into and remain in treatment can stop using drugs and see improvements in their occupational, social, and psychological functioning.8 How Effective is Drug Addiction Treatment?However, rehabilitation treatment plans must be individualized, and the type of treatment that you will receive depends on the extent and nature of your problem and the types of treatment services that will best help you to address underlying problems. Getting the best outcome from rehabilitation depends on your participation in a treatment plan of adequate duration to address your individual needs. The length of time needed varies by individual. Generally, for residential or outpatient treatment, treatment lasting longer than 90 days is recommended to achieve positive, lasting results.8 How Long Does Drug Addiction Treatment usually last?
Therefore, it will be important for you to discuss the length of your treatment plan with your treatment team, as this will vary. Your treatment team will also consider your Medicare coverage, since insurance plans may have set limits, and your treatment team may need to advocate for you to make sure that you get all the treatment that is needed based on your medical and personal history and the severity of any substance use disorders. For more information on this, you can go online to HealthCare.gov and search for “mental health and substance abuse coverage” to find more details on coverage plans.
What Are Medicare Eligibility Requirements?
People who qualify for Medicare are those age 65 and older, people under 65 with disabilities, those who have been receiving social security benefits for at least 24 months, and people with end-stage renal disease, or permanent kidney disease, who are on dialysis or have a transplant.
Social Security’s definition of a disability is different than other programs, and your disability must be qualified by a physician before you apply to Social Security and/or Medicare for the qualification of disability:9
- You cannot do work that you did before because of your medical condition.
- You cannot adjust to other work because of your medical condition.
- Your disability has lasted or is expected to last for at least 1 year or to result in death.
If you qualify for Medicare meeting the above requirements, Medicare can cover substance abuse treatment and can cover alcohol misuse screening and counseling.3
There are multiple parts to Medicare, but the main ones are Part A, Part B, and Part D.1 There is also another plan called Medicare Advantage, or Part C.10
- Medicare Part A is premium-free if you are age 65 or older and covers services related to hospitalization expenses.
- Medicare Part B helps cover healthcare services like doctor appointments and many outpatient treatments.4
- Medicare Part D will help cover prescription drugs that are related to your treatment plan.
- Medicare Part C, also known as Medicare Advantage, is an all-in-one alternative to the typical bundled plan of Medicare Parts A, B, and D. This plan will have lower out-of-pocket costs, but you will need to ensure that the provider that you use is within your plan’s network.
When diagnosed with a substance use disorder, your doctor or treatment team will check your coverage. If you are covered under Medicare, most mental health services provided by doctors or other healthcare professionals will require that you pay 20% of the Medicare-approved amount, after your Part B deductible is met. If you need medication, Medicare Part D will help cover any medication that may be provided by your physician or treatment plan.
Substance use disorder treatment is covered by many insurance plans, including Medicare. With the passage of the Affordable Care Act and the Mental Health Parity and Addiction Equity Act of 2008, insurance carriers including Medicare are now required to provide equal coverage for mental health or substance use disorders as those provided for general medical complaints.11
American Addiction Centers (AAC) can provide comprehensive and individualized rehabilitation services for people covered under Medicare who are seeking recovery from addiction and substance abuse, and for co-occurring mental health disorders. AAC works with a variety of insurance plans, including Medicare, and your information is always kept strictly confidential.
Call our toll-free 24/7 confidential helpline and one of our helpful and professional staff will help guide you through the process of getting your treatment plan started.
- US Department of Health and Human Services. (2014). Who is eligible for Medicare?
- US Centers for Medicare and Medicaid Services. (2021). Medicaid & CHIP coverage.
- US Centers for Medicare and Medicaid Services. (2021). Alcohol misuse screenings and counseling.
- US Department of Health and Human Services. (2014). What is Medicare Part B?
- Department of Health and Human Services Centers for Medicare and Medicaid Services. (2019). Medicare coverage of substance abuse services.
- Substance Abuse and Mental health Services Administration. (2020). Co-occurring disorders and other health conditions.
- Department of Health and Human Services Centers for Medicare and Medicaid Services. (2020). Medicare and your mental health benefits.
- National Institute on Drug Abuse. (2018). Principles of drug addiction treatment: A research-based guide (third edition).
- Social Security. (2021). Disability benefits | how you qualify.
- S. Centers for Medicare and Medicaid Services. (2021). Your Medicare coverage choices.
- Substance Abuse and Mental Health Services Administration. (2021). Laws and regulations.