Several reputable sources, such as the National Institute on Alcohol Abuse and Alcoholism (NIAAA), have reported that substance and alcohol abuse have been under-diagnosed in America’s senior population. According to the National Library of Medicine (NLM), in 2020, it’s estimated that nearly 6 million older adults will have some form of substance use disorder (SUD). The most common forms of substance abuse and addiction among seniors stem from the misuse of alcohol, certain prescription drugs, and over-the-counter medications. The NIAAA states that nearly 20% of seniors abuse either alcohol or prescription drugs. Because of this, Medicare has made it a point to cover medically necessary treatments and programs to rehabilitate seniors with a substance use disorder.
Types of addiction services covered by Medicare
The American Society of Addiction Medicine (ASAM) has established a list of the most effective types of treatment for substance use disorders. They are as follows:
- Case Management
- Cognitive-behavioral approaches
- Group, individual, marital, or family counseling
- Psychiatry
Medicare offers coverage for these services, as well as other substance misuse and addiction services. Other services Medicare covers include, but are not limited to, the following:
- Alcohol misuse screenings and counseling
- Inpatient rehabilitation care
- Medication management
- Partial hospitalization
- Smoking cessation counseling
- Screening, brief intervention, and referral to treatment
Alcohol misuse screenings and counseling
The alcohol misuse screening is available to any adult Medicare beneficiary who uses alcohol but isn’t dependent on alcohol. The screening is covered once a year at 100% if your doctor accepts Medicare assignment. If the doctor concludes that you are misusing, you can receive up to four counseling sessions a year in a primary care setting.
Inpatient rehabilitation care
If your doctor confirms you need rehabilitation, medical supervision, and care from both doctors and therapists, Medicare may cover inpatient rehabilitation care for you. You must be diagnosed with a medical condition that qualifies you for this type of care. If approved, Medicare will cover a semi-private room, meals, nursing and rehabilitation services, prescription drugs, and other medically necessary services. You will be responsible for a 20% Part B coinsurance and the Part B deductible if you haven’t met it for the year.
Medication management
Medicare’s Medication Therapy Management program allows your doctor and pharmacist to review the medications you take and create an action plan to make sure you are making the best use of your prescription drugs. This is a free service if you qualify for it. To see if you qualify for this program, you must contact your Part D, plan provider.
Partial hospitalization
Partial hospitalization care is similar to inpatient rehabilitation care, but with partial hospitalization, you go home after treatment instead of staying in a facility. This type of care is less intense than inpatient rehab but more intense than treatment in your doctor’s or therapist’s office. Among other services, partial hospitalization includes occupational therapy and individual training and education for your specific condition. Your providers must accept Medicare assignment for Medicare to approve the service.
Smoking cessation counseling
Medicare covers smoking cessation counseling to help you stop using tobacco. Medicare covers up to eight visits each year at 100% if your doctor accepts Medicare assignment.
Screening, brief intervention, and referral to treatment (SBIRT)
Screening, brief intervention, and referral to treatment (SBIRT) is an intervention process that was developed for providers so they can intervene before the substance use turns to abuse.
First, the provider will use the Medicare structured assessment screening to assess whether you are at risk for substance abuse. Next, the provider may have up to five counseling sessions with you. If your provider feels you need additional services, they will refer you for treatment with a specialist.
How to qualify for addiction services covered under Medicare
While these services can have their own set of qualifications, generally, to qualify for addiction services, your doctor must demonstrate they are medically necessary to treat or diagnose a medical condition, you must have an established plan of care written by your doctor, you must use a Medicare-approved facility when receiving services, and your doctor’s staff must code each service according to Medicare’s requirements.
Depending on the service, you may also need to meet the criteria for either alcohol abuse or alcohol dependence. If you’re unsure whether you qualify for any of these services, talk with your primary care provider.
