Can Medicare Cover Addiction Treatment/Substance Abuse

Substance abuse is a growing epidemic across the country. According to the National Survey on Drug Use and Health (NSDUH), nearly 20 million American adults struggle with a substance use disorder every year. Almost 38% of adults in 2017 battled an illicit drug use disorder. Drug abuse and addiction cost U.S. society more than $740 billion in missed work productivity, healthcare expense, and costs relating to crime. It’s a serious problem, and it merits direct consideration. People who struggle with substance use disorders need proper treatment, but treatment costs money. Millions of Americans rely on Medicare and other government-sponsored programs for their health insurance. Does Medicare cover treatment for addiction and substance abuse? Read on to learn about how Medicare addresses coverage for substance abuse and addiction treatments.

Medicare Eligibility

Medicare is a federal health insurance program that provides healthcare coverage for qualifying individuals over the age of 65. Individuals may be eligible for Medicare if they are either (a) aged 65 or older, (b) under 65 but diagnosed with a disability, or (c) under 65 but suffering from end-stage renal disease (kidney failure necessitating dialysis or a transplant).

Individuals with low incomes may also be eligible for Medicaid, which can be used to supplement Medicare coverage. Medicaid may be able to provide coinsurance and cover mental healthcare services that Medicare is not able to cover.

Medicare Covers Substance Abuse Treatment

The short answer is that Medicare will, in fact, cover rehabilitation treatments for alcohol and drug addiction. Substance use disorder is a real, debilitating illness, and treatment merits coverage through private and public insurance providers. Depending on the patient’s need, Medicare may cover a variety of addiction treatment services including, but not limited to:

• Psychotherapy
• Patient education programs concerning diagnosis and treatment
• Substance use counseling
• Toxicology testing
• Individual and group therapy sessions
• Skilled nursing care
• Inpatient rehabilitation care
• Activity therapies
• Diagnostic testing
• Occupational or family therapy
• Prescription drugs administered while in the hospital or at a medical office
• Certain outpatient prescription drugs, so long as they are deemed medically necessary to treat substance use disorder
• Screening, Brief Intervention, and Referral to Treatment (SBIRT), a screening and intervention technique geared toward individuals who are receiving primary care and a potential substance use issue is identified

There are limitations on the amount of coverage Medicare will provide. For example, Medicare sets a 190-day limit on inpatient treatment at specialty psychiatric hospitals. Once the 190-day lifetime limit is reached, Medicare will no longer cover psychiatric hospitalization, which can pose difficulties for individuals who need frequent or lengthy inpatient psychiatric care.

Requirements for Medicare Coverage of Substance Addiction Treatments

While Medicare will provide coverage for substance abuse treatment, the patient must satisfy certain requirements in order to obtain coverage. Specifically, the following must apply:

• The patient’s healthcare provider must deem the addiction treatment services medically necessary
• The patient must receive addiction care at a Medicare-approved facility or from a provider approved by Medicare
• The patient’s healthcare provider must establish a plan of care

If you are a healthcare provider or employer who would benefit from a variety of qualified and passionate psychiatric care specialists, reach out to Orbit Health to discuss your options for telepsychiatry today.