Medicare Health Insurance Coverage for Alcohol & Drug Rehab

Medicare is federal public health coverage for people ages 65 and older, in addition to some people under age 65 who have disabilities or specific health conditions. About 60 to 65 million people currently access health insurance through Medicare. Original Medicare has several parts: Part A, Part B, and Part D.

Another option is to get a Medicare Advantage plan, known as Medicare Part C, which offers the same coverage as Original Medicare with some additional benefits and limitations. Medicare Advantage plans are offered by private insurance companies rather than the federal government.

Does Medicare Cover Addiction Treatment?

Original Medicare and Medicare Advantage plans generally cover medically necessary mental health and substance abuse treatment. The amount of out-of-pocket costs you pay, such as your copayment, coinsurance, and deductible, may vary depending on your specific plan options.

Different types of treatment are covered by different parts of Original Medicare. For example, Medicare Part A covers hospitalization and, therefore, would be the coverage that applies to inpatient or residential treatment. Medicare Part B covers doctor’s visits and outpatient addiction care. Medicare Part D covers many of the prescription drugs used for mental health and substance use treatment, although coverage may depend on where the medication is administered.

Medicare Advantage plans operate similarly to private insurance. You’ll get at least as much coverage as Original Medicare and often additional benefits as well. You’ll usually have specific copayments instead of paying a percentage of the cost in coinsurance. However, you may need to stay within the plan’s provider network to get coverage, and you may need referrals to visit specialists such as mental health professionals and addiction treatment centers.

What Types of Addiction Treatment are Covered by Medicare?

Original Medicare and Medicare Advantage both cover medically necessary treatment. You can work with your doctor to get a treatment plan showing what levels of care you need and for how long.

Inpatient drug rehab, delivered in a clinic or a hospital, is covered by Medicare Advantage plans or Original Medicare Part A when an inpatient setting is medically necessary. There can be limits on the number of days covered depending on the type of facility, so be sure to check your plan details.

Original Medicare may cover partial hospitalization, or day programs, that are located in a hospital outpatient department or community mental health center if you meet specific requirements. Here, patients attend treatment during the day and return to their homes at night. PHP program sessions often take place for 4-8 hours a day, three to five days a week, and provide at least 20 hours of treatment a week. Day programs typically last for 3-4 weeks, but it can go up to several months.

Original Medicare and Medicare Advantage also cover intensive outpatient substance abuse rehab treatment. Intensive outpatient programs typically involve 9 to 20 hours of treatment per week, with these hours spread over 3 to 5 days. Intensive programs generally last around 90 days and include individual, group, and family counseling, and addiction and relapse prevention education. This category also includes medication assisted treatment (MAT).

Medicare Advantage and Original Medicare Part B cover telehealth visits for substance use disorder and co-occurring mental health disorders along with mental health treatment and behavioral health services. For these services you don’t have to worry about being in a rural medical facility — you can receive them at home.

How Did Medicare Mental Healthcare Change in 2024?

The most significant change to Medicare substance abuse coverage that occurred on January 1, 2024, is the inclusion of additional mental health providers who are now eligible to be reimbursed by Medicare for their services and can therefore be more available to Medicare patients.

Previously only psychiatrists and psychologists along with clinical social workers were Medicare eligible providers. Now licensed professional counselors and mental health counselors along addiction counselors are Medicare eligible. The list also includes marriage and family therapists and alcohol and drug counselors.

This long awaited change makes it possible for many clients who could not afford to pay out of pocket for their treatment to access the services they need. According to the American Counseling Association about 200,000 new mental health counselors will enroll as Medicare providers.

Does Medicare Cover Methadone & Suboxone (MAT)?

Medicare covers opioid use disorder treatment (OUD) services using MAT that includes methadone and buprenorphine (Suboxone) along with naltrexone (Vivitrol). Original Medicare coverage applies and you only pay the Part B deductible when you get the medications and supplies through an approved Opioid Treatment Program (OTP).

If you get your medications and supplies through a different clinic or pharmacy you may need to pay Part B copays and you may need to use a Part D prescription plan to get the medication. Medicare Part A is hospital insurance and will cover MAT during inpatient treatment.

If you have a Medicare Advantage plan you’ll need to check with your insurance company to find in network providers and learn more about your out of pocket costs.

What to Do if Medicare Won’t Cover the Cost of Rehab

Medicare is selective about which programs are covered and some centers may not accept Medicare due to lower payouts. That means you may face a situation where Medicare won’t cover the substance use treatment you’re interested in.

It’s still important to get the care you need. You can look into whether you also qualify for Medicaid, which can allow you to get a Dual Eligible plan that offers more coverage. Another option is to look for a treatment program that has a sliding scale of fees based on income where you can get affordable high quality care.

Some treatment facilities offer scholarships or payment plans that can make it easier to afford care. You may also be able to borrow money from friends and family. The most important thing is that you get the treatment you need to break free from substance use.

Can I Travel Out of State for Treatment With Medicare?

This is an important question because with Original Medicare, the answer is yes you can see any Medicare approved provider. However if you have a Medicare Advantage plan you are often limited to the plan’s medical network.

You can switch from Advantage back to Original Medicare during open enrollment but you’ll need to be sure to buy a Part D drug plan to go with Parts A & B. You’ll also want to be mindful of the changes in out of pocket costs because Medicare charges a percentage coinsurance rather than a set copayment. It’s not necessarily more — although it can be — but it’s definitely different.

Medicare advantage plans can be Health Maintenance Organizations (HMO) or Preferred Provider Organizations (PPO). These plans will have different networks and different rules about whether you can get coverage for out of network care. Communicating with the insurance company is the best way to know if a treatment is covered and what deductibles or copays apply along with what medications are supported and other details.