Medicare can be used to pay for certain types of alcohol and drug rehab and treatment. But there are many variables to this access, including what type of rehab you or your loved one need and where you’re seeking treatment. Many private treatment facilities don’t readily accept Medicare or Medicaid, but there’s an increasingly urgent need for these types of resources.
Data from the National Institute on Drug Abuse indicates that nearly one million American adults over the age of 65 currently live with substance use disorder and that over the past decade, the number of people in this age group seeking treatment for substance use disorder has doubled from 3.4 to seven percent. At the same time, over 44 million adults over the age of 65, 15 percent of the United States population, are enrolled in the Medicare program.
As experts forecast that this number will reach 79 million by 2030, it’s reasonable to expect that this population as well as seniors in need of addiction care will overlap. Seniors live on fixed income and, even though they retire from their careers, it’s harder to retire from alcohol or drug addiction. This is why it’s important that the elderly have robust resources to make substance use care more affordable and accessible. If you or an elderly loved one are seeking Medicare coverage for alcohol or drug rehab, here is some information that may help you.
Am I Eligible for Medicare?
You or your loved one are likely eligible for Medicare:
- You’re 65 years of age or older.
- You are younger than 65 and have a disability.
- You are younger than 65 and have end stage renal disease (permanent kidney failure that requires dialysis or a transplant).
Eligibility may be affected by income thresholds and other factors, specific to each individual patient who seeks care.
How Do I Get Medicare to Cover Rehab?
In order to get Medicare to coverage for rehab or substance use disorder treatment, you must meet the following criteria:
- Your doctor or care provider deems rehab a medical and behavioral necessity.
- You get treatment at a facility that accepts and is approved by Medicare.
- Your plan of care is determined by your doctor or care provider.
Your plan of care includes the scope and frequency of rehab services you receive, including medication, therapy, counseling and more.
Does Medicare Cover Alcohol Rehab?
Yes, Medicare generally covers treatment for a full range of substance use disorder, including alcohol use disorder. As is the case with other types of substance abuse, your care provider must deem treatment for alcohol abuse or addiction medically necessary in order for you to receive coverage. The American Psychological Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-V) lists the criteria for alcohol use disorder as the presence of two or more of the following physical and behavioral symptoms in the past year.
Criteria for alcohol use disorder:
- You had times when you ended up drinking more, or longer than you intended.
- You wanted to cut down or stop drinking, or tried to, but couldn’t on multiple occasions.
- You’ve spent a lot of time drinking or being sick or getting over the after-effects.
- You experienced craving — a strong need, or urge, to drink.
- You found that drinking — or being sick from drinking — often interfered with taking care of your home or family or caused job troubles or school problems.
- You continued to drink even though it was causing trouble with your family or friends.
- You’ve given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink.
- You’ve gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex) on multiple occasions.
- You continued to drink even though it was making you feel depressed or anxious or adding to another health problem or after having had a memory blackout.
- You had to drink much more than you once did to get the effect you want or found that your usual number of drinks had much less effect than before.
- You found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, or sweating or sensed things that were not there.
Talk to your doctor or care provider if you’re experiencing these or any other phenomena related to drinking. The National Institutes of Health reports that less than 10 percent of those who are struggling with alcohol use disorder actually receive it. Prolonged, untreated binge drinking becomes a more urgent problem as we get older and our bodies become less able to quickly metabolize alcohol, making the need for Medicare-approved alcohol rehab programs incredibly important. For those who feel they drink too much, but don’t fall under the criteria for alcohol use disorder, Medicare Part B covers an annual alcohol misuse screening.
What Types of Rehab and Treatment Services Does Medicare Cover?
Medicare covers a broad range of inpatient and outpatient, the exact scope of which is broken down under Parts A and B.
Medicare Part A covers inpatient treatment services. Inpatient care requires patients to stay in a residential facility while they heal from substance use disorder. These programs typically last 30-60 days.
Medicare covers a variety of inpatient services including:
- Inpatient Hospital Care (Including Detox and Withdrawal Management)
- A Semi-Private Room
- Nursing Services
- Drugs (Excluding Opioid Maintenance Drugs)
Medicare will not cover a private room (unless medically necessary), phone or TV in the room or personal items, like toiletries, comfort and quality-of-life items. Medicare Part B will cover doctors’ service administered in an inpatient or residential facility.
Medicare Part B
Medicare Part B will cover outpatient rehab and partial hospitalization program (PHP) alcohol and drug rehab. PHP rehab is a more in-depth version of outpatient care, in which patients may also be able to stay in sober living residences during their stay.
Outpatient alcohol and drug rehab services covered by Medicare Part B include:
- Group Therapy
- Individualized Counseling
- Screenings and Assessments
- Occupational Therapies (CBT, DBT, EMDR, etc.)
- Family Counseling
- Activity-Based Therapies
- Lab Tests
- Prescription Drugs Which Must Be Given by Your Care Provider
- How Long Will Medicare Cover Rehab
Medicare generally covers 80 percent of the Medicare-approved amount required to pay for these rehab components. Services can be administered by licensed general practitioners, nurse practitioners, physicians’ assistants, psychiatrists, clinical psychologists, clinical social workers, and clinical nurse specialists. Medicare Part B also covers opioid use disorder treatment using approved medications, like Suboxone® and Vivitrol® if they are administered by an opioid treatment program that’s enrolled in Medicare, and the Part B deductible applies.
How Long Will Medicare Pay for Rehab?
Medicare generally covers inpatient rehab for up to 60 days of inpatient care.
The cost breakdown is as follows:
- Days 1-60: $1,364 Deductible
- Days 61-90 – $341 Daily Copay
After day 90, a $682 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime). Each day after the lifetime reserve days, patients are required to pay all costs of their rehab care. The exact number of days Medicare will pay for rehab will vary, according to each patient’s specific plans and resources.
What to Do When Medicare Runs Out for Rehab
When Medicare is no longer able to cover your rehab, you will need to stay out of the hospital or a skilled nursing facility (SNF) for 60 days in a row before attempting to enroll in a Medicare-approved treatment program again. Luckily, most inpatient treatment programs are at least partially covered for the entire duration of their stay. For more information on the specifics of your eligible Medicare rehab coverage, talk to a representative for a full plan verification. Don’t let confusion over logistics and planning stop you or your loved one from getting the help you need. Start your treatment now.