Dear Marci,

I’m helping my father set up his treatment for substance use disorder. Does Medicare cover this kind of care?

-Saul (Arlington, VA)

Dear Saul,

Yes, Medicare should cover alcoholism and substance use disorder treatment for your father if:

His provider states that the services are medically necessary
He receives services from a Medicare-approved provider or facility
And, his provider sets up his plan of care
Medicare covers treatment in both inpatient and outpatient settings. Here are just a few examples of the services that Medicare covers:
Psychotherapy
Opioid treatment program (OTP) services
Patient education regarding diagnosis and treatment
Post-hospitalization follow-up
Part A should cover his care if he is hospitalized and needs substance use disorder treatment. If he is in an inpatient psychiatric hospital, keep in mind that Medicare only covers a total of 190 lifetime days. Once this limit has been reached, though, Medicare may cover care at a general hospital. A plan’s cost-sharing rules for an inpatient hospital stay should apply.

Part B should cover outpatient substance use disorder care he receives from a clinic, hospital outpatient department, or opioid treatment program. Original Medicare covers these services at 80% of the Medicare-approved amount. As long as he receives the service from a participating provider, he will pay a 20% coinsurance after meeting his Part B deductible. Visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to find participating providers. If he is enrolled in a Medicare Advantage Plan, contact his plan for information about costs, coverage, and in-network providers for substance use disorder treatment.

I hope this information is helpful to you and your father. Wishing him well on his recovery.

-Marci

Dear Marci,

What mental health care does Medicare cover? I have anxiety and depression, and my primary care provider recommended I see a therapist or psychiatrist.

-Josefina (Cleveland, OH)

Dear Josefina,

Medicare covers both inpatient and outpatient mental health care. And Medicare prescription drug plans cover medications used to treat mental health conditions, but be sure to check the formulary to ensure the brands and dosages you take are included.

Medicare Part B covers outpatient mental health care, including the following services:

Individual and group therapy
Substance use disorder treatment
Tests to make sure you are getting the right care
Occupational therapy
Activity therapies, such as art, dance, or music therapy
Training and education (such as training on how to inject a needed medication or education about your condition)
Family counseling to help with your treatment
Laboratory tests
Prescription drugs that you cannot administer yourself, such as injections that a doctor must give you
An annual depression screening

Be sure to ask any provider you see if they take your Medicare insurance before you begin receiving services. If they don’t, you will likely be responsible for the full cost of the care. Psychiatrists are more likely than any other type of physician to opt out of Medicare, meaning Medicare will not cover any of the cost of the care from those doctors. Additionally, not all non-medical providers (like psychologists or clinical social workers) are Medicare-certified. If you need a list of providers near you who accept Medicare, you can go to www.medicare.gov/care-compare.

Medicare Part A covers inpatient mental health care that you receive in either a psychiatric hospital (a hospital that only treats mental health patients) or a general hospital. Your provider should determine which hospital setting you need.

If you receive care in a psychiatric hospital, Medicare covers up to 190 days of inpatient care in your lifetime. If you have used your lifetime days but need additional mental health care, Medicare may cover your care at a general hospital.

Medicare Part D covers most prescription drugs used to treat mental health conditions. You may have Part D coverage through a Medicare Advantage Plan or through a stand-alone Part D plan. All Part D plans must cover at least two drugs from most drug categories and must cover all drugs available in certain categories, including antidepressants and antipsychotic medications.

I hope this helps!

-Marci

Dear Marci,

I usually get very nervous before my doctor’s visits. My doctors are wonderful, but medical appointments have always felt overwhelming to me, and I forget to ask the questions I wanted to ask. How should I prepare for appointments and make the most of my time with my doctors?

-Vinnie (Phoenix, AZ)

Dear Vinnie,

It’s understandable to be nervous or overwhelmed at medical appointments. I think many people share your feelings! Communication is key in building good relationships with your doctors and getting the best possible care. I would recommend the following tips to make the most of your appointments and to feel your best.

First, be prepared. Leading up to your appointment, think about what you would like to tell and ask the doctor. Make a list of this information and these questions and bring it to your visit. Also consider whether you want to bring another person to your appointment, like a family member, friend, or caregiver. It’s sometimes helpful to have another person with you, whether for emotional support or asking questions. It may calm your nerves to pack a bag before your visit to ensure you don’t forget anything important. Pack your bag with all of your insurance cards (for example, Medicare, Medicaid, Medigap, and/or Medicare Advantage cards), any relevant documents or health history, your list of questions, and something for taking notes.

Next, share information. Tell your doctor about any current symptoms or concerns during your visit. If there are several, consider ranking them in order of how much they are affecting or troubling you. Tell your doctor if you are having trouble with activities of daily living, such as bathing or dressing. Also inform your doctor about other health care providers (like specialists or therapists) you have seen and any treatments they have prescribed or recommended. Health issues can be hard to talk about, but it is important that your doctor has as much relevant information from you as possible so they can recommend the best possible care. If your doctor does not specifically ask for information that you think is important, tell them. 

Ask questions.  If you do not understand something your doctor says, ask them to explain it.  Don’t be afraid to ask the same question more than once, or to ask if your doctor can explain something in a different way, if you need more time to process an answer. If you need further clarification, consider scheduling a phone conversation or speaking to a nurse or other provider. 

Get it in writing. Ask your doctor to write down what you should do between now and your next visit. This may include instructions for how to take medications, specialists you should see, and/or lifestyle modifications. 

And finally, follow up. If you experience problems after your appointment, or if you have symptoms that get worse, call your doctor’s office to schedule a follow-up appointment. You may also need to make a lab appointment or find out how to access test results.  It could be helpful to learn if your doctor uses any form of electronic communication, like email or an online portal. These can help you communicate questions and look up previous appointments and lab/test results without having to call the doctor’s office directly. 

I hope these tips help you prepare for your next doctor’s appointment and feel a little more confident. Best of luck!

-Marci

Dear Marci,

My doctor is recommending I get surgery. I do trust them but I want to get another opinion before agreeing to something so big. Will Medicare cover a second opinion, even if another doctor recommends the same thing?

-Rana (El Paso, TX)

Dear Rana,

For our other readers, a second opinion is when you ask a doctor other than your regular doctor for their view on symptoms, an injury, or an illness you are experiencing in order to better help you make an informed decision about treatment options. 

There are countless reasons why someone would want a second opinion, but here are just a few examples:

You have a rare condition with which another doctor may have more experience or training.
Your doctor recommends a treatment that is risky, invasive, involves surgery, or has lifelong consequences.
You want assurance that you’ve considered all treatment options.
You believe your diagnosis could be incorrect.
 
Original Medicare covers second opinions if a doctor recommends that you have surgery or a major diagnostic or therapeutic procedure.

Medicare will also cover a third opinion if the first and second opinions are different from each other.

The second and third opinions will be covered even if Medicare will not ultimately cover your procedure. Do note, however, that Medicare does not cover second and third opinions for excluded services, such as cosmetic surgery.
  
If you have a Medicare Advantage Plan, your plan may have different cost and coverage rules for second and third opinions. Contact your plan for more information about costs and restrictions.  

Some people may feel uncomfortable or nervous asking their doctor for a second opinion. Doctors are professionals and most will respect your want for a second opinion. Many consider it standard medical practice to get another opinion. In fact, your doctor may even be ready to give you referrals for a second opinion. Trust yourself and remember that you are your strongest advocate!

-Marci

Dear Marci,

I learned that Medicare may cover home health care for people who are homebound. How do I know if I am considered homebound?

-Alejandro (Madison, WI)

Dear Alejandro,

That’s a great question. As you said, Medicare covers home health care if you qualify. One of the requirements to qualify is that you be homebound. But what exactly does this mean?

Medicare considers you homebound if both of the following apply to you:

You need the help of another person or medical equipment to leave your home. For example, you need crutches, a walker, or a wheelchair to leave your home. Or, your doctor believes that your health or illness could get worse if you leave your home
And, it is difficult for you to leave your home and you typically cannot do so

Your doctor should decide if you are homebound based on their evaluation of your condition. If you qualify for Medicare’s home health benefit, your plan of care will also certify that you are homebound. After you start receiving home health care, your doctor is required to evaluate and recertify your plan of care every 60 days.

Even if you are homebound, you can still leave your home for medical treatment, religious services, or to attend a licensed or accredited adult day care center, without putting your homebound status at risk. Leaving home for short periods of time or for special non-medical events, such as a family reunion, funeral, or graduation, should also not affect your homebound status. You may also take occasional trips to the barber or beauty parlor.

I hope this helps as you and your doctor consider your needs for home health!

-Marci