Medicare is the national healthcare program for those 65 and older and with certain disabilities. Each Medicare beneficiary has different medical needs and health conditions, so knowing how your health insurance will cover you or someone you know when a specific condition arises is important.
The National Institute on Alcohol Abuse and Alcoholism found that 17% of adults 60 and older are affected by prescription and alcohol abuse. As people grow older, they experience life-changing events or continue to hold onto trauma from years prior, causing them to be more vulnerable to substance misuse. Once addiction sets, an individual may look to drug rehabilitation for assistance.
What is drug rehabilitation?
According to the American Addictions Center, drug rehabilitation is used to provide care and recovery from addictions. Drug rehabilitation facilities offer additional resources that some individuals may need to overcome the addiction. Some facilities specialize in particular addictions, while others include a wide range of treatment and services. You can even find facilities that focus on specific age groups.
The two main settings for treatment are inpatient and outpatient. However, the services provided can range with each setting.
How does Original Medicare cover drug rehabilitation?
Medicare Part A would cover inpatient hospital admittance. If the provider certifies that your care requires intensive services and treatment with supervision, they may believe it is medically necessary for you to be admitted as an inpatient. In this situation, you would be responsible for the Part A deductible, which is $1,484 in 2021. If you are in the hospital for more than 60 consecutive days, you will start paying a daily copay.
Outpatient services can be covered by Medicare Part B. These services include screenings, group and individual therapy, counseling, and more. Each Medicare beneficiary gets one alcohol misuse screening per year. If the provider determines you are misusing alcohol, you will get four face-to-face counseling sessions each year.
Medicare Part B can also cover opioid treatment and services in a treatment program. The opioid program would include medication counseling, therapy sessions, and drug testing.
There is an annual deductible of $203 in 2021, and once you meet your deductible, Medicare will pay 80% of all Medicare-approved services. If you enroll in a Medigap plan, your plan can help cover the Part A deductible, additional hospital costs, and the Part B 20% coinsurance.
Does Part D offer drug rehabilitation coverage?
Part D plans provide prescription coverage. Each plan must follow the same federal guidelines and cover at least two drugs in each therapeutic class. Three of those classes are antipsychotics, antidepressants, and anticonvulsants. If certain medications are prescribed as part of your treatment, you may have coverage with your Part D plan.
Part D plans have a list of covered drugs called the formulary. You will want to check your plan’s formulary to know which drugs are covered and which ones aren’t. If your plan does not cover a medication you need, you can request a formulary exception, and if it is denied, you are responsible for 100% of the cost of the drug.
How do Advantage plans cover drug rehabilitation?
Medicare Advantage plans must cover what Original Medicare covers. The Advantage plan should cover drug rehabilitation services covered by Medicare Part A and Part B, but your cost-sharing will vary. You may experience a copayment or coinsurance for therapy visits, counseling, and particular treatments. Your Medicare Advantage Plan’s Summary of Benefits will list all covered services and your cost-sharing.
Providers for treatment
Providers that can perform rehabilitation services include physicians, clinical psychologists, clinical nurse specialists, nurse practitioners, and clinical social workers. If you have Original Medicare with a Medigap plan, you can see any provider accepting Medicare. However, if you have an Advantage plan, you will want to be sure they accept your specific plan.
Depending on the drug rehabilitation services you need, Medicare may cover them. The setting in which you receive your rehabilitation will determine what part of Medicare will provide coverage. Don’t be afraid to ask questions and express concerns with your provider when you are unsure if your insurance will cover a service.