Medicare coverage on Alcoholism and Substance Abuse

Medicare covers alcoholism and substance use disorder treatment in both inpatient and outpatient settings if your provider states that the services are medically necessary. You receive services from a Medicare-approved provider or facility and your provider sets up your plan of care.

Services covered include but not limited to;

• Patient education regarding diagnosis and treatment
• Psychotherapy
• Post-hospitalization follow-up
• Opioid treatment program (OTP) services 
  • Food and Drug Administration (FDA)-approved opioid treatment medications (methadone, buprenorphine, naltrexone). This includes dispensing and administering the drug, if applicable, Substance use counseling, Individual and group therapy, Toxicology testing and Intake activities and periodic assessments
• Prescription drugs administered during a hospital stay or injected at a doctor’s office
• Outpatient prescription drugs covered by Part D
  • Part D plans must cover medically necessary drugs to treat substance use disorder
    • Part D plans cannot cover methadone or similarly administered medications to treat substance use disorder, but they can cover methadone for other conditions, such as pain. 
• Structured Assessment and Brief Intervention (SBIRT) services provided in a doctor’s office or outpatient hospital. SBIRT is covered by Medicare when the individual shows signs of substance use disorder or dependency.  Treatment involves:
• Screening: Assessment to determine the severity of substance use and identify the appropriate level of treatment.
• Brief intervention: Engagement to provide advice, increase awareness, and motivate individuals to make behavioral changes.
• Referral to treatment: Provides them with more treatment and access to specialty care.

Inpatient care

Medicare Part A should cover your care if you are hospitalized and need substance use disorder treatment. Also, your plan’s cost-sharing rules for an inpatient hospital stay should apply.

If you are receiving care at an inpatient psychiatric hospital, keep in mind that Medicare only covers a total of 190 lifetime days.

Outpatient care

Medicare Part B should cover outpatient substance abuse care you receive from a clinic, hospital outpatient department, or opioid treatment program. Today, some substance use disorder treatment can also be provided using technology services, this is what we call telehealth or telemedicine. 

Original Medicare covers mental health services at 80% of the Medicare-approved amount. This includes treatment for alcoholism and substance use disorder. You will pay a 20% coinsurance after you meet your Part B deductible as long as you receive the service from a participating provider,. If you are enrolled in a Medicare Advantage Plan, contact your plan for cost and coverage information for substance use disorder treatment. Your plan’s deductibles and copayments/coinsurance may apply.

Drug coverage

Some medications used to treat substance use do not meet certain requirements for coverage under Medicare Part D. They are generally not covered by Part D or Part B, however, these medications can be covered by Part A during an inpatient stay or by Part B as part of medication-assisted treatment (MAT) at an OTP.

Opioid treatment programs

Medicare Part B covers opioid use disorder (OUD) treatment received at opioid treatment programs. OTPs, which are also known as methadone clinics, are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) to provide methadone as part of medication-assisted treatment. OTPs are the only place where you can receive methadone to treat opioid use disorder.

To receive Medicare coverage for OTP services, your OTP must be certified by SAMHS and enrolled in the Medicare program.