My friend thinks she may need treatment for alcohol and substance abuse. Although she is willing to get treatment, she is worried about how much it will cost. She has Original Medicare—does Medicare cover services related to alcoholism and substance abuse?
Your friend’s provider states that the services are medically necessary
Your friend receives services from a Medicare-approved provider or facility
And, your friend’s health care provider sets up a plan of care.
Some of the services that Medicare cover include, but are not limited to:
Patient education regarding diagnosis and treatment
Psychotherapy
Post-hospitalization follow-up
Prescription drugs administered during a hospital stay or injected at a doctor’s office
Methadone may be covered in inpatient hospital settings, but it is not covered in outpatient clinics where it is supplied orally.
Outpatient prescription drugs covered by Part D
Part D plans must cover medically necessary drugs to treat substance abuse
Part D plans cannot cover methadone or similarly administered medications to treat substance abuse, but they can cover methadone for other conditions, such as pain
Structured Assessment and Brief Intervention (SBIRT) services provided in a doctor’s office or outpatient hospital. SBIRT is covered by Medicare when an individual shoes signs of substance abuse or dependency. SBIRT treatment involves:
Screening: Assessment to determine the severity of substance abuse and identify the appropriate level of treatment.
Brief intervention: Engagement to provide advice, increase awareness, and motivate an individual to make behavioral changes.
Referral to treatment: If an individual is identified as having additional treatment needs, provides them with more treatment and access to specialty care.
If your friend receives inpatient care, her care will be covered by Part A and cost-sharing rules of an inpatient hospital stay should apply. Note that if your friend receives care at an inpatient psychiatric hospital, Medicare only covers a total of 190 lifetime days. If your friend uses all 190 lifetime days but needs further inpatient care, she can get Medicare-covered care at a hospital.
If your friend receives outpatient treatment, Part Bwill cover her care. Original Medicare covers mental health services, including treatment for alcoholism and substance abuse, at 80% of the Medicare-approved amount. As long as your friend receives services from a provider who takes assignment (accepts Medicare’s approved amount as full payment for a service), your friend will pay a 20% coinsurance after she meets her Part B deductible.
If your friend is still concerned about the cost of her care, you or she can consider programs that might help her save money on her health care costs. These programs include Medicaid, the Medicare Savings Programs (MSP), and Extra Help. To learn more about these programs and get help enrolling, you or your friend can call her State Health Insurance Assistance Program (SHIP). To find her SHIP, you can call 877-839-2675 or visit www.shiptacenter.org.