Medicare is a national health insurance program for people aged 65 or older. It also provides care for those with disabilities or kidney failure. Medicare insurance covers 60 million Americans. It means that a massive portion of the U.S. population depends on it for accessing Medicare rehab care.
Does Medicare cover rehab? And how long does Medicare pay for rehab? All people with this coverage must understand what their policy allows for and how to use it for substance abuse treatment.
Does Medicare Cover Rehab for Addiction?
Medicare coverage does not have a specific benefit category for substance abuse therapy. However, this does not mean that it fails to cover them. In most cases, the services used for drug rehab fall under the umbrella of behavioral health services. It is a category that means that the program does cover drug rehab for anyone enrolled in the program across the United States.
However, there are restrictions. With Medicare rehab coverage, the primary limitation is that covering the care must be necessary for the patient, and the coverage is limited to what is within reason. And, of course, the individual must be eligible for and enrolled in Medicare.
Who Is Eligible For Insurance?
Medicare Is Reasonably Restrictive in Who It Will Cover:
- The first class of people is those who are 65 or older
- The second are younger people who have disabilities that qualify them for early coverage
- Finally, anyone with end-stage renal disease requiring dialysis or a transplant
For those 65 and older, there are still some restrictions. The insurance is divided into parts, with the two most commonly noted being Part A—hospital insurance—and Part B—Medicare insurance.
Part A Can be Accessed Without Paying a Premium If:
- A person or their spouse paid Medicare taxes for at least ten years.
- They are receiving retirement benefits from Social Security or the Railroad Retirement Board.
- They are eligible for these benefits but have not yet filed for them.
- They or their spouse had Medicare-covered government employment.
Anyone can quickly determine their eligibility for drug rehab coverage or other forms of coverage. They simply need to use the eligibility tool.
Criteria For Drug Rehab Coverage
Once someone is eligible for rehab, they need to enroll. After enrollment, however, they do not just have open access to alcohol rehab insurance or any other form of rehabilitation.
There Will Still Be Criteria That the Individual Must Meet; These Criteria Are:
- Their provider states that the specific rehab services being sought are medically necessary for the patient.
- The services are rendered by an approved provider or Medicare rehab facility
- Their provider sets up the plan of care
If these criteria are met, the insured individual should access coverage for rehabilitation. Still, it is possible that the services covered will be limited. For example, insurance plans will not cover treatment in a private drug rehabilitation facility.
Substance Abuse Services Covered
Given that Medicare rehab coverage is not open-ended, anyone looking to use it for addiction recovery must know what the limits are. All essential elements of rehab are covered, but some extras or alternative therapies are not.
Below Are the Services Most Commonly Covered:
- Patient education centered on diagnosis and treatment
- Post-hospitalization follow-up
- Prescription drugs administered during a hospital stay or injected at a doctor’s office
- Methadone could be covered in inpatient hospital settings but not in outpatient clinics
- Outpatient prescription drugs covered by Part D
- Structured Assessment and Brief Intervention (SBIRT) services provided in a doctor’s office or outpatient hospital
If someone is interested in a therapy not listed here as being part of drug rehab coverage, there is the possibility insurance will still cover it. They should consult with their local health services department to determine if the rehab therapy they want could be covered.
Inpatient Rehab Treatment
Inpatient treatment is part of hospital care, which means that it falls under Part A. Medicare coverage for the rehabilitation facility is governed by the patient’s plan’s cost-sharing rules. So whatever their plan lists for an inpatient hospital stay will apply to coverage of treatment for alcoholism and drug abuse.
How long does Medicare pay for rehab? It is important to note that it does place limits on how long someone can stay in inpatient rehab. The program covers a maximum of 190 days in a person’s lifetime.
Outpatient Rehab Treatment
Outpatient treatment is rendered at a clinic or hospital outpatient department. Medicare will pay for 80% of the costs of treatment.
If the individual has an Advantage Plan, they will need to contact the plan to find out their costs for outpatient care.
Medicare rehab coverage days are not limited to outpatient treatment like they are for residential facilities.
Partial Hospitalization Treatment
Medicare offers coverage for partial hospitalization treatment. It is a day treatment program where the patient receives intense psychiatric treatment during the day but gets to return to their home at night. For such a program to be covered for substance abuse, the patient must be working with a physician who certifies and recertifies their need for treatment. They must also receive, at minimum, 20 hours a week of PHP therapy. Because this is an outpatient treatment, and the patient doesn’t stay in a facility overnight, it is covered under Part B.
Standing for Screening, Brief Intervention, and Referral to Treatment, SBIRT services allow for early intervention in individuals who engage in substance abuse but are not yet addicted. Medicare rehab coverage helps users connect with this service when they have severe non-addicted substance use or meet the criteria of substance use disorder without dependence.
SBIRT services prevent problematic use from turning into an addiction or resulting in the user’s death. SBIRT services are offered in primary care settings, and as such, are included under Part B.
It Can Be Broken Down As Follows:
- A structured assessment is used to determine if the patient is engaging in risky substance use behaviors
- The patient is involved in a short conversation with feedback and advice, which serves as an intervention
- The patient is referred to treatment based on the results of their assessment
SBIRT services must be provided by someone licensed by the state to perform mental health services that are qualified for the specific services rendered, and they must be working within their State Scope of Practice Act. If the provider and the insured meet the criteria, health insurance for this form of drug rehab will be covered.
Medicare coverage plans can be placed into two categories: Original and Advantage. These two types are pretty similar but have some key differences.
|Includes Part A and Part B||Includes Part A, B, and D|
|Users can enroll in Part D separately||Users automatically have Part D|
|Supplemental insurance is often needed||Supplemental insurance is not allowed|
|Users tend to pay more out of pocket||Out-of-pocket costs tend to be lower|
|Vision, hearing, and dental are not covered||Vision, hearing, and dental may be covered|
|Users can see any doctor who accepts the insurance||Users must stick with doctors in their network|
|Referrals are generally not required||Referrals generally are needed|
|There is no yearly limit||There is a yearly limit|
Which plan is best for Medicare rehab coverage will depend on the needs of the individual. Before someone selects a plan, they need to understand the alphabet soup of Medicare.
Medicare Part A is hospital insurance.
- Inpatient care in a hospital or hospital-like setting
- Skilled nursing facility care
- Hospice care
- Home health care
It is the type of insurance used whenever someone seeks coverage for rehabilitation in an inpatient facility.
Part B is medical insurance covering everything outside the scope of hospital care.
- Services from doctors and other healthcare providers
- Outpatient care
- Home health care not covered under Part A
- Durable medical equipment
- Preventative services
Outpatient Medicare rehab facility, partial hospitalization, and SBIRT are covered under Part B.
Part C is just another name for the Advantage plan. Understanding it means knowing what Parts A, B, and D are and how they apply to drug rehab.
Part D is Medicare’s prescription drug coverage. It covers the cost of prescription drugs and is offered by private insurance companies that follow the rules set. In addition, it includes substance abuse medication coverage.
Drugs That Can Be Covered and Used for Addiction Treatment Include:
- Acamprosate calcium
- Buprenorphine HCl
- Buprenorphine HCl
- Naloxone HCl (Narcan)
- Naltrexone HCl
How To Apply For Medicare Coverage Plan
If someone determines they are eligible for coverage, they can head to their local Social Security office to apply.
Users must actively sign up as no one is automatically enrolled. Once approved, the person must decide what coverage they want: Original or Advantage plan. After that, it is just a matter of ensuring they understand their coverage and know how to use it.
Seeking Rehabs that Take Medicare
Anyone interested in enrolling in rehabs that take Medicare coverage should first determine if they are eligible. If they are, they need to take steps to enroll and then verify where they can seek treatment. With drug rehab coverage, it is possible to access quality rehabilitation care with the benefit of saving some costs.
If you are eligible for the insurance and need addiction treatment, take the first step today. The skilled staff at rehabilitation facilities can help overcome the nightmares of addiction. However, if the idea of inpatient rehab doesn’t sound too appealing and you wish to return home in the evening – an outpatient rehab is an option. Choosing rehabs that take Medicare insurance will save you the cost without compromising the benefit and quality of addiction treatment.
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- Who is eligible for Medicare? HHS.gov. 2014. https://www.hhs.gov/answers/medicare-and-medicaid/who-is-eligible-for-medicare/index.html
- Medicare. Estimate my Medicare eligibility & premium. https://www.medicare.gov/eligibilitypremiumcalc/
- Treatment for alcoholism and substance use disorder. Medicare Interactive. https://www.medicareinteractive.org/get-answers/medicare-covered-services/mental-health-services/treatment-for-alcoholism-and-substance-abuse