Does Medicare Cover Addiction Rehab?

Active addiction to substances, including alcohol, is a disease. And like all diseases, it needs to be treated. For this reason, Medicare classifies addiction treatment as a medically necessary service.

In this MedicareWire article, we’ll examine how each part of Medicare covers the different aspects of addiction treatment and rehabilitation.

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Substance use disorder, also known as addiction, is when you are unable to control your use of a harmful substance.
Addiction rehabilitation can help you recover from withdrawal symptoms and manage addictive behaviors.
Medicare will cover addiction rehab if your doctor determines it is medically necessary.
Medicare Part A will cover inpatient rehabilitation facilities when required.
Medicare Part B provides coverage for counseling, screening, and outpatient facility services for addiction rehab.
Medicare Advantage plans will cover the same addiction rehab services as Part A and Part B, but you will be restricted to in-network providers.
Most prescription drugs needed for rehabilitation will be covered by a Part D plan.

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What Is Addiction?

A substance use disorder, commonly known as an addiction, is a condition that inhibits your ability to control your use of a substance, drug, or medication. When you experience addiction, you will continue to use that substance despite any harmful effects it does to you and you may be more willing to perform rash actions and behaviors to enable your addiction. This can affect your ability to function appropriately in daily life, causing issues in school, work, and social interaction.[mfn referencenumber=1]Mayoclinic.org, “Drug addiction (substance use disorder): Symptoms & causes“, Accessed December 2, 2021[/mfn]

When you use a substance too frequently, you develop a tolerance to the substance and require a larger amount to achieve the beneficial effect you are craving. Failing to fulfill this addiction can lead to withdrawal symptoms that severely affect your mental and physical health.[mfn referencenumber=1]Mayoclinic.org, “Drug addiction (substance use disorder): Symptoms & causes“, Accessed December 2, 2021[/mfn]

Addiction Rehabilitation

If you or a loved one are experiencing an addiction, seeking medical help and addiction rehabilitation will help lead to recovery. Addiction rehabilitation, often shortened to rehab, is often a combination of several different treatments, such as:[mfn referencenumber=2]Mayoclinic.org, “Drug addiction (substance use disorder): Diagnosis & treatment“, Accessed December 2, 2021[/mfn]

Detoxification
Behavioral therapy
Self-help support groups
Medication
Counseling on substance use

How Does Medicare Cover Rehab?

Medicare covers drug and alcohol rehabilitation for its beneficiaries. However, there are rules about the providers you can use with Medicare. Also, some types of addiction treatment are not covered by Medicare. Certain conditions must be met before Medicare will cover treatment:[mfn referencenumber=3]Medicare.gov, “Medicare & Your Mental Health Benefits“, Accessed December 2, 2021[/mfn]

Your provider must deem that the services are medically necessary.
You must receive care at a Medicare-approved facility or from a Medicare-approved provider.
Your provider must set up a plan of care.

In some cases, Medicare will also cover services related to Screening, Brief Intervention, and Referral to Treatment (SBIRT). These services are intended to help those who may be at risk of developing substance use disorder. Like all other services Medicare covers, the SBIRT services must be deemed medically necessary.[mfn referencenumber=4]CMS.gov, “Screening, Brief Intervention, & Referral to Treatment (SBIRT) Services“, Accessed December 2, 2021[/mfn]

Medicare Part A – Inpatient Rehab

If you require addiction rehab in an inpatient rehabilitation facility (also known as an inpatient rehab facility, IRF, acute care hospital, or rehabilitation hospital), Medicare Part A will provide coverage for the service. Your doctor will have to verify that your condition requires this level of continual supervision and coordinated care to facilitate your rehabilitation. Rehabilitation facility services covered by Part A include:[mfn referencenumber=5]Medicare.gov, “Inpatient rehabilitation care“, Accessed December 2, 2021[/mfn]

Rehabilitation services, such as physical therapy, occupational therapy, and speech-language pathology
A semi-private room
Meal services
Nursing services
Medically necessary drugs
Other necessary hospital services and supplies

If you are receiving addiction rehab care in a psychiatric hospital (rather than a general hospital), Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime.[mfn referencenumber=3]Medicare.gov, “Medicare & Your Mental Health Benefits“, Accessed December 2, 2021[/mfn]

While you are in an inpatient care facility, Medicare Part A will not cover these services:[mfn referencenumber=3]Medicare.gov, “Medicare & Your Mental Health Benefits“, Accessed December 2, 2021[/mfn]

Private duty nursing
A phone or television in your room
Personal items, like toothpaste, socks, or razors
A private room, unless medically necessary

Medicare Part B – Outpatient Rehab

Many health care services for substance misuse and addiction rehab are covered by Medicare Part B. This includes outpatient rehab services such as:[mfn referencenumber=6]Medicare.gov, “Mental health care (outpatient)“, Accessed December 2, 2021[/mfn]

Individual and group psychotherapy with licensed professionals
Alcohol and drug misuse screening (once per year)
Psychiatric evaluation
Prescription drugs that require a doctor to https://medicarewire.com/wp-content/uploads/2024/06/Geisinger-logo-1.svgister them
Mental health care (partial hospitalization)
Outpatient hospital services (observation, lab work, durable medical equipment)

Medicare Part B will not cover the following services for your addiction rehab:[mfn referencenumber=3]Medicare.gov, “Medicare & Your Mental Health Benefits“, Accessed December 2, 2021[/mfn]

Meals.
Transportation services to or from a mental health care service.
Activity therapy for recreation or distraction from other issues.
Support groups for discussion and socialization. (Note: Not the same as group psychotherapy, a Medicare-approved service.)
Testing or training for job skills that aren’t part of your rehabilitation.

Medicare Advantage – Part C

Medicare Advantage Plans are required to provide coverage for the same services as Medicare Part A and Part B (Original Medicare). This means that your Medicare Advantage Plan will cover your addiction rehabilitation. Some plans also offer prescription drug coverage as part of being a member of their particular plan, which can help cover your doctor prescribed medications for treating addiction.[mfn referencenumber=7]Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 2, 2021[/mfn]

However, Medicare Advantage members will be required to use services, facilities, and providers within their plan’s network. Your out-of-pocket costs after Medicare Advantage has paid their share may differ from Original Medicare’s out-of-pocket costs.[mfn referencenumber=7]Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 2, 2021[/mfn]

Medicare Part D

If you require prescription medication as part of your addiction rehab, it will usually be covered by your Medicare Part D plan. Depending on your Part D plan, you may have to pay an annual deductible before the Part D begins paying its share, as well as a copayment per prescription.[mfn referencenumber=8]Medicare.gov, “What Medicare Part D drug plans cover“, Accessed December 2, 2021[/mfn]

Medigap

Even after Original Medicare provides coverage for your rehabilitation, it can be difficult to handle the out-of-pocket costs that remain. Thankfully Medicare supplement insurances (Medigap) are available for purchase by private insurance companies. A Medigap policy will cover some or all of the out-of-pocket costs for Medicare-approved services, including rehabilitation services. These costs include:[mfn referencenumber=9]Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed December 2, 2021[/mfn]

Deductibles
Coinsurance
Copayments