Does Medicare cover addiction

Substance abuse and addiction are two serious, usually undetected issues among older adults. Addiction usually goes undetected in seniors since many symptoms from common senior conditions are similar to substance abuse.

However, the National Institute on Alcohol Abuse and Alcoholism has confirmed that at least 17% of seniors 60 and older suffer from alcohol and/or prescription addiction.

There are two main types of seniors who are substance abusers. The first group is users who have been abusing for many years by the time they turn 65, or early-onset abusers. The other group is users who started their substance abuse later on in life, perhaps after the death of a spouse, also called late-onset abusers.

Regardless of when the substance abuse started, Medicare covers treatments and programs for addiction.

Psychotherapy and general office visits

A couple of services Medicare covers that may be needed for addiction treatment are general doctor visits and psychotherapy.

Psychotherapy can be done in a group or individual setting. Medicare simply requires that the professional who runs the session accepts Medicare assignment and is licensed in the state where treatment is received. If the professional accepts Medicare assignment, the only cost of the visit may be the Part B annual deductible and the Part B coinsurance.

General office visits with a primary care provider are also covered under Part B. These visits are also subject to the Part B deductible and coinsurance. In 2020, the Part B annual deductible is $198, and the coinsurance is 20% of the allowed cost. A primary care provider can also perform an annual depression screening that’s covered 100% under Part B.

Partial Hospitalization Program

Occasionally, when substance abuse is more on the severe side, a doctor may recommend the Partial Hospitalization Program (PHP). This program’s treatment is similar to the treatment given to inpatients in a psychiatric hospital. However, the difference is that the patient doesn’t stay overnight in the hospital. Instead, the patient returns home each day and only goes to the hospital during the day for treatment sessions.

The program is usually customized to fit the patient’s medical needs, but generally, the program includes psychotherapy, occupational therapy, patient education, and family counseling. Medicare requires that a minimum of 20 hours of care is provided each week under the program and that the physician in charge of care continually certifies that the patient needs the treatment.

Also, the treatment must be provided at a Medicare-approved hospital or mental health center. Medicare Part B also covers this type of treatment, and the deductible and coinsurance apply.

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

One approach that Medicare covers is the Screening, Brief Intervention, and Referral to Treatment (SBIRT) service. If the substance use hasn’t turned into abuse yet, but the beneficiary is using an addictive substance, then SBIRT may be recommended.

SBIRT usually starts in a primary care setting where the doctor will screen the patient for substance abuse. Based on the results of the screening, the doctor may engage in intervention type conversation with the patient to educate them on the risks of their substance use. If the doctor feels further treatment is necessary, he will refer the patient to have specialized treatment.

Since SBIRT is an outpatient service like the services mentioned above, it will also be a Part B service. Therefore, the deductible and coinsurance apply. Part B covers medically necessary outpatient services.

Treatment for opioid abuse

Medicare Part D is the prescription drug coverage under the Medicare program. Part D plans are sold by private insurance carriers. While each plan can vary by price and covered drugs, every Part D plan must include coverage for prescription treatment of opioid abuse.

Under this coverage, Part D must cover certain prescription drugs that are used to treat opioid addiction when prescribed by a doctor for that purpose. While there are some restrictions to this coverage, generally, the prescription can be covered by filing a formulary exception if the drug isn’t already covered by the plan.

Medicare covers a wide array of treatment services for addiction and substance abuse. If you feel you or a family member needs any of these services, reach out to your doctor.

Danielle K. Roberts is a Medicare insurance expert and co-founder at Boomer Benefits, where her team of experts help baby boomers with their Medicare decisions nationwide.