How medicare covers substance abuse is an important topic given that “[a]lcohol and drug problems, particularly prescription drug abuse, among older adults is one of the fastest growing health problems facing the country,” according to The National Council on Alcoholism and Drug Dependence (NCADD). Today’s guest author, Danielle Kinkle Roberst, explains how one might use medicare to help them treat a substance abuse problem. Danielle Kunkle Roberts is a Medicare expert based in Fort, Worth, TX. She and her team help thousands of new beneficiaries with their Medicare plan choices each year. You can learn more at BoomerBenefits.com. You can learn more about Danielle on her LinkedIn page.

How Medicare Covers Substance Abuse by Danielle Kunkle

Every year Medicare spends millions of dollars treating depression and substance abuse disorders in the elderly. The National Council on Alcoholism and Drug Dependence has reported that over 2.5 million older adults currently suffer from alcohol or drug problems.

There are many reasons. Once we retire, we often have less social interaction, creating a sense of loneliness. As we get older, we might also lose loved ones or watch our children and grandchildren become adults and move away. We have more aches and pains and sometimes develop chronic health conditions. All of this contributes to the rising number of seniors with substance abuse disorders.

Fortunately, Medicare will help cover both the outpatient and inpatient care for substance abuse. There are also voluntary options to help cover the prescription drugs related to your treatment.

Substance Abuse Care Under Original Medicare

Original Medicare consists of two parts, Part A and Part B. If you receive your treatment and care in an inpatient setting, Part A will cover it. Inpatient care can include your room, meals, and even medication administered to you while in the hospital.

Depending on what kind of hospital you receive care from, Part A may cover up to 190 days of inpatient care. This is a limit that is per lifetime for mental healthcare. Once those 190 days are used up, you won’t be able to obtain additional days in a psychiatric inpatient facility.

However, if after 190 days, you still need additional treatment, you may be able to switch to a general hospital for your care. Medicare will cover part of your care there as well.

Outpatient care is the treatment you receive outside of a hospital setting. Some examples of outpatient care are follow up doctor visits, lab testing, and visits with a psychiatrist. Your outpatient care will be covered by Part B as long as you’re the provider accepts Medicare.

With Medicare, like any insurance plan, you will be expected to pay copays and deductibles for each part. For example, Part A currently has a deductible of $1340, and Part B has an annual deductible of $183. Once that deductible is met, Part B will pay for 80% of your treatment and care. You will be responsible for the other 20%.

Coverage for Co-Occurring Disorders

Many individuals with a substance abuse disorder also suffer from a co-occurring mental illness such as depression, anxiety, bipolar disorder or post-traumatic stress. Sometimes a patient may be using substances as a form of self-medication, while other times the use of drugs or alcohol causes the onset of mental illness or makes that underlying illness worse.

Medicare Part B covers an annual depression screening at no cost to you. Your doctor can administer a patient health questionnaire or other standardized depression screening tool to assess your mental health and identify your risk for depression or mood disorders.

If your Medicare doctor advises that you need psychotherapy or group counseling to help you deal with these disorders, Part B will pay for this medically necessary care. Your cost-sharing is the same as it is for substance abuse care.

Medicare pays 80% of the cost of any outpatient therapy, psychiatric assessments, diagnostic exams or group counseling while you pay for the other 20%.

If inpatient care or partial hospitalization is needed to deal with your depression, this will fall under Part A just as it does for substance abuse inpatient care.

Gap Coverage for Original Medicare

Deductibles and copays are considered the gaps of Original Medicare. Luckily, Medicare offers additional coverage for these gaps. The two types of gap coverage you can apply for are Medigap plans and Medicare Advantage plans.

Medigap plans, also known as Medicare Supplement plans, fill in the gaps in Medicare to provide you with comprehensive coverage. Plan F is known to provide coverage for all of the gaps. However, Plan G has become a popular choice in recent years when choosing Medigap plans. Plan G covers all of your out-of-pocket expenses except your $183 Part B deductible.

Medicare Advantage plans, or Part C, combine your Original Medicare and usually your prescription drug coverage that is mentioned below. Advantage plans have lower monthly premiums than Medigap plans and depending on the type of patient you are, can be a more suitable choice for some people.

These plans have networks, so you’ll need to check that your substance abuse care providers are in the network before joining one. You will also pay copays as you go along, so be aware that sometimes there are more back-end expenses when you enroll in a Medicare Advantage plan.

Medicare Prescription Drug Coverage

Once you leave the hospital or if you are receiving outpatient care, your doctor may prescribe medications to help you overcome addiction. Medicare offers prescription drug coverage through Part D. Each Part D drug plan has a formulary which lists the medications that that plan covers.

Medicare requires drug plans to cover a wide range of medications to ensure there is no discrimination towards certain health conditions. Some classes of drugs, like antidepressants, must be covered.

However, it is imperative that you review each drug plan’s formulary to make sure that you enroll in a drug plan that covers your specific prescriptions.

If you or a loved one is in need of substance abuse care and you need to speak with someone about your specific Medicare coverage, contact a Medicare insurance broker that can answer all of your questions and explain your options.

Medicare beneficiaries can also visit the Substance Abuse and Mental Health Services Administration website and use their Behavioral Health Treatment Services Locator to find a facility nearby or call SAMHSA’s National Helpline at 1-800-662-HELP (4357) for free and confidential information.