Does Medicare cowl rehab for drug and alcohol dependancy? Sure, and right here’s precisely what it’s going to pay for

In accordance with the 2022 National Survey on Drug Use and Health (NSDUH), in 2022, about 4 million folks aged 65 or older (or 7%) had a substance use dysfunction (SUD) previously yr, together with 2.3 million who had an alcohol use dysfunction (AUD) and 1.8 million who had a drug use dysfunction (DUD).

Older adults often feel ashamed about substance abuse and are reluctant to hunt assist. However assist is on the market by Medicare protection.

What Medicare covers for rehab

“Medicare pays for the treatment of alcoholism and substance use disorders in both inpatient and outpatient settings, when medically necessary,” says Meredith Freed, Senior Coverage Analyst for Medicare Coverage at KFF.

Medicare Part A covers inpatient substance abuse therapy. Medicare Part B covers outpatient substance abuse therapy from a hospital outpatient division or clinic.

Expenses covered for the therapy of alcoholism and substance use issues embrace:

• Remedy
• Affected person schooling
• Observe-up after hospitalization
• Pharmaceuticals by Medicare Part D (outpatient)
• Pharmaceuticals, together with Methadone (inpatient)
• Structured Evaluation and Temporary Intervention (SBIRT)

With out a analysis of SUD, however if you’re exhibiting early indicators of substance abuse or dependency, chances are you’ll qualify for SBRIT, which is an outpatient early intervention course of with these three components: 

• A screening evaluation for dangerous substance use behaviors
• A short intervention with a affected person who reveals dangerous substance use
• A referral for remedy or extra therapy 

If you happen to want inpatient therapy at a hospital or therapy facility, you’ll pay the usual deductible for every inpatient hospitalization, which, in 2024, is $1,632. After that, “Medicare covers expenses up to 60 days, then beneficiaries pay a $400 copayment per day for days 61-90 and $800 per day up to the lifetime reserve days available,” says Freed. For inpatient stays in a psychiatric hospital (as a substitute of a common hospital), Medicare protection is restricted to as much as 190 days of hospital providers in a lifetime.

Medicare Benefit protection for rehab

Medicare Advantage (MA) plans are required to supply not less than the identical protection as conventional Medicare plans.

Nevertheless, in accordance with Freed, the deductible and copay quantities (see above) are for folks in conventional Medicare. MA plans have the pliability to change value sharing for many Half A and B providers, topic to some limitations. So should you’re in an MA plan, your cost-sharing necessities might look completely different. For instance, MA plans typically cost day by day copayments for inpatient hospital stays.

Listed below are some extra examples of value financial savings instruments MA plans use:

• Prior authorization necessities. In accordance with KFF analysis, nearly all MA enrollees (98%) in 2022 had been in plans that required prior authorization for some psychological well being and substance use dysfunction providers.
• Protection just for in-network suppliers. In 2022, roughly 60% of MA plan contributors had plans that didn’t cowl out-of-network outpatient psychological well being and substance use dysfunction providers.
• Referral necessities. A few quarter (26%) of MA contributors had been in plans requiring referrals for some psychological well being and substance use dysfunction providers in 2022.

Medigap and Medicaid protection for rehab

If in case you have supplemental Medicare insurance coverage (comparable to Medigap) along with your conventional Medicare, you possibly can usually get protection for deductibles and different dependancy therapy bills not coated beneath primary Medicare.

Medicaid protection varies by state. Verify together with your Medicaid state agencies for extra data.

Extra assist for substance use dysfunction in 2024

One of many greatest challenges in receiving assist for psychological well being challenges comparable to substance use dysfunction is the shortage of psychological well being suppliers. Lately handed Congressional motion that goes into impact in 2024 might assist.

CMS introduced that over 400,000 marriage and household therapists and psychological well being counselors can present providers to folks on Medicare and receives a commission instantly. Beforehand they needed to be supervised by a billing doctor, says Freed.

CMS additionally put forth a brand new requirement that MA plans embrace an “adequate number of outpatient behavioral health facilities” of their supplier networks for remedy and substance use dysfunction therapy.

Congress and CMS additionally made progress on closing the hole between inpatient and outpatient SUD therapy, to take impact in 2024.

Beforehand, Medicare supplied a partial hospitalization benefit (PHP), for sufferers who want not less than 20 hours of remedy and different psychological well being and substance use dysfunction providers in per week as a substitute of requiring inpatient hospitalization.

“In 2024, Medicare beneficiaries will have access to a new program—intensive outpatient (IOP) services,” says Freed. As an alternative to hospitalization, sufferers can obtain 9-20 hours of outpatient SUD providers in a bigger number of settings, together with hospital outpatient departments, neighborhood psychological well being facilities, federally certified well being facilities, rural well being clinics, and opioid therapy packages (OTPs). Beforehand, these providers had been solely out there for individuals who wanted 20 or extra hours of providers, which may solely be offered in hospital outpatient departments and neighborhood psychological well being facilities.