Using Medicare for Drug or Alcohol Treatment
What is Medicare?
Medicare is a federal health insurance program for those who are 65 and older, as well as those with specific health issues. The Medicare program offers high-quality medical care to seniors all over the country, with over 90 million Americans covered through Medicare Parts A, B, or Medicare Advantage (Part C).1
For Medicare beneficiaries that have struggled with substance use, the program can also help with substance use treatment. Medicare rehab coverage will depend on your specific plan and whether you have Original Medicare or a Medicare Advantage plan. Understanding what parts of addiction treatment Medicare covers and how to access these beenfits can help you find treatment and live a healthier life in recovery.
Does Medicare Cover Addiction Treatment?
Medicare may cover some or all of the cost of addiction treatment. The Affordable Care Act (ACA) requires all long-term health insurance plans are required to offer coverage for behavioral health services. These services can include treatment for substance abuse and co-occurring mental health disorders.2
If you are not currently on Medicare, the first step is to ensure you qualify for it. To get Medicare coverage, you need to be an American citizen or permanent resident who has lived in the country for at least five years. You will also need to meet at least one of the following conditions:
- You’re age 65 or older.
- You’re under 65 but disabled and receiving disability benefits from Social Security or the Railroad Retirement Board.
- You have end-stage renal disease (ESRD).
- You have Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease.3
Once you’ve determined your eligibility for Medicare, you’ll need to enroll in the program. Many Americans are automatically enrolled in Medicare Parts A and B, but some need to sign up for it. If you want a Medicare Advantage plan instead of Original Medicare, you will need to sign up for the plan you have chosen. You can sign up by contacting your nearest social security office.4
The exact level of coverage, and what programs are covered, will depend on your medical needs and the Medicare plan you have. Original Medicare includes a national network of providers, but each Medicare Advantage plan has a limited network based on where you live. You may not be able to get coverage outside of the network if you have an Advantage plan.5
Next, you need to search for rehabs that take Medicare. As with all health insurance plans, individual rehabs can choose what coverage to accept. For example, American Addiction Centers had facilities that accept both Original Medicare and Medicare Advantage, while other facilities may only accept Medicare Advantage. Some may not accept Medicare at all. It’s important to determine whether a facility accepts Medicare before committing to treatment.
Types of Addiction Treatment Medicare Covers
Medicare is divided into parts. There’s not a specific part that covers mental health and substance abuse treatment. As a result, the coverage will come from the part of Medicare that is most relevant for treatment.
The parts of Medicare are:
- Medicare Part A, which covers inpatient hospital care.
- Medicare Part B, which covers doctor’s visits, outpatient care, medical equipment, and more.
- Medicare Part D, which covers prescription medication.
There’s also Medicare Part C or Medicare Advantage. This program is an entire replacement for Original Medicare offered by private insurers and often includes additional benefits. However, it also comes with a limited network of medical providers.6
Services that are covered by Medicare may include inpatient services that are reasonable and necessary like detox or rehab. Medication provided as part of inpatient treatment may be paid in a bundle with the inpatient care, rather than being billed separately to your prescription coverage.7
Outpatient detox or rehab in an outpatient setting may also be covered, however, it’s covered on a service-by-service basis rather than in a bundled payment to the facility. Medications that are not self-administered are covered under Part B, but other prescriptions would be billed separately under Medicare Part D.7
A Partial Hospitalization Program (PHP) is an intensive treatment that lands between inpatient and outpatient addiction treatment. To be covered by Medicare, a doctor must certify that you need a minimum of 20 hours of care per week in a PHP, and the services must be recognized by Medicare. These programs include counseling, therapy, and learning skills that help you create new habits for a healthy life.7
Another option your doctor has is Screening, Brief Intervention, and Referral to Treatment (SBIRT). This is an early intervention that occurs before you develop a dependency on substance use and can help prevent problems from becoming more serious. These services can be provided in your doctor’s office, making it easier to access care.7
Overall, Medicare could potentially cover a wide range of addiction treatment and mental health services. It’s best to speak to a Medicare representative to determine the extent of your coverage.
How to Use Medicare for Addiction Treatment
To use Original Medicare substance abuse treatment, your doctor needs to review your case and recommend a specific treatment plan. The provider must certify that the services are medically necessary, and you need to choose drug rehab centers that accept Medicare coverage. In addition, you’ll need a specific plan of care set up by your provider, and then follow through on that process.
If you have a Medicare Advantage plan, the process may be similar. However, since Advantage plans are private insurance plans, there could be other requirements. Be sure you contact your insurance provider to review your coverage and ensure that the program you’re interested in is within your provider network.
How to Check Your Medicare Rehab Benefits
There are several ways to check your Medicare benefits and to see which rehab programs or detox centers accept Medicare. One of the best ways is to contact a Medicare representative. Medicare.gov operates an online website where members can check their coverage online. You can also call Medicare’s member services phone number to review your rehab options and ensure that your coverage will provide the help you need. There are also many third-party sites that allow you to check your coverage online.
Can I Use Medicaid and Medicare for Rehab or Detox?
Medicaid is a state-based program that helps lower-income Americans get the medical care they need. Some Medicare beneficiaries are also eligible for Medicaid, depending on their income and what state they live in.
Being eligible for both programs is known as being “dual-eligible.” In this case, Medicare pays first for your care, and then Medicaid pays second. So if you choose a program that accepts both Medicare and Medicaid, you may not have any out-of-pocket costs.8
If you choose to use your Medicaid and Medicare coverage for treatment, it’s important to choose a rehab facility that will accept those programs for payment. Some may accept Medicare, but not Medicaid; it’s always best to confirm with facility representatives before pressing ahead with treatment.
Detox Centers and Rehab Programs That Accept Medicare
While Medicare can help you cover the cost of substance or drug abuse treatment, you’ll still need to find a facility that accepts Medicare insurance. Medicare has an approved amount they will pay for each service, and each program can decide if they accept those payment levels or not. It’s important to find a facility that accepts Medicare.
You can also call our confidential detox and rehab hotline anytime, 24/7, to ask any questions about how to use Medicare to get substance use treatment. We can also help connect you to facilities that accept Medicare coverage. Choosing to move toward a life free of substances is courageous, and we’re here to help.