Does Medicare cover Substance Abuse?

by Danielle Kunkle Roberts

Not so long ago, health insurance policies had fairly limited coverage for substance abuse. It wasn’t until Obamacare rolled onto the scene when we finally saw some real improvements because these services got added to the list of essential benefits all plans must include.

People recovering from addiction today have better substance abuse and mental health treatment than we did just ten years go. That’s because new health insurance plans under the Affordable Care Act must now include treatment for substance abuse disorders, behavioral health and mental health.

Even better, there are no set waiting periods and it doesn’t matter if the substance abuse is pre-existing. Care is available with no annual or lifetime limits, and that care must be of equal quality to care for other medical conditions. In other words, you cannot be discriminated against simply because the care you need is for mental health or substance abuse.

As with any care, you should always check to make sure your chosen treatment provider is in network with your health insurance carrier.

So, we’ve got pretty good care options for substance abuse care for people under 65. But what about people on Medicare? Let’s take a look at how Medicare covers treatment for substance abuse and other mental health disorders.

Substance Abuse Care under Medicare

Medicare provides coverage for people age 65 and over and for some younger individuals with certain disabilities or health conditions. Substance Abuse care under Medicare is fairly robust, including both inpatient and outpatient benefits.

Medicare Part A will cover substance abuse treatment that you receive at any treatment center that accepts Medicare. Medicare covers up to 190 days of inpatient treatment per lifetime. Part A might also cover methadone that you are given for opiate addiction while in an inpatient facility.
Outpatient care for substance abuse falls under Part B. After a small annual deductible, Part B will pay for 80% of the cost of substance abuse treatment. In addition, Medicare Part B provides full coverage for alcohol abuse screening.

Medicare Part B outpatient services include therapy, education, and office visits for follow-up care as well as any drugs administered in a hospital of treatment facility.

Part B also will cover the Structured Assessment and Brief Intervention screening and intervention process. This important process can be helpful in identifying individuals who are at risk for abusing substances.

It’s important to remember that Medicare Part B only pays for 80% of these covered services. This could result in significant out-of-pocket spending for you if your treatment plan calls for several weeks or months of care. Fortunately, Medigap plans are available to help you pay for the rest and for things like deductibles and copay.

When you first enroll in Medicare, you will have an Initial Enrollment Period to explore different types of coverage that can help you fill in these gaps. This includes both Medigap plans, which supplement Original Medicare, and Part C Medicare Advantage options.

Lastly, retail outpatient medications are available through Medicare Part D, which is considered your outpatient drug coverage. While this coverage is considered voluntary, it is an important part of any well-rounded Medicare coverage package. We never know when we might need prescription drug treatment, so it’s not wise to skip enrolling in Part D unless you have access to other creditable healthcare coverage.
All Part D drug formularies do include drugs that are commonly prescribed to treat addiction. Each Part D plan is required to offer medications for medically necessary opioid dependence.

If you are new to Medicare and have questions about how Medicare might cover future substance abuse care, speak with a reputable Medicare insurance broker who can help you explore your options.

Danielle Kunkle Roberts and her team at Boomer Benefits help Medicare beneficiaries navigate Medicare.

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