As noted in a prior post Medicare Pathways is looking at the most popular New Year’s Resolutions and providing information on how Medicare can help follow through with the resolution.

Coming in third on the list of most popular New Year’s Resolutions: Stop Drinking

Surprisingly, alcohol and substance abuse (other than tobacco) among the older population is a growing problem for the healthcare industry. Although alcohol and substance abuse is statistically at epidemic proportions among the elderly, it remains for the most part unreported, undiagnosed, or ignored. The reasons why substance abuse by our senior citizens goes undetected are varied. Most drinkers who started late are affected by social isolation and physical health problems. Many are affected by grief or loss, and others affected by housing, marital, and mental health problems.

The cost for treatment of substance abuse-related cases cost more to treat because they require almost 26% more hospital staff and other resources than discharges that are unrelated to substance abuse. Because these substance abuse-related cases tend to be more expensive to treat than the average hospital case, the amount actually paid out by Medicare for substance abuse-related care accounted for 23% or nearly one-fourth of the total Medicare payments for hospital care, according to the National Center on Addiction and Substance Abuse (CASA) at Columbia University.

Medicare has you covered if your New Year’s Resolution is to stop drinking!

Original Medicare will help pay for treatment of alcoholism and drug abuse in both inpatient and outpatient settings under the following circumstances: You receive services from a Medicare-participating provider or facility; your doctor states that the services are medically necessary; and your doctor sets up your plan of treatment.

If you are hospitalized, or receive inpatient treatment, original Medicare Part A helps pay for your care for alcohol and substance abuse treatment. Your out-of-pocket costs are the same as for any other type of hospital stay. However, it is important to note that if you are admitted to a psychiatric hospital for substance abuse or alcohol treatment, original Medicare Part A only covers a total of 190 days spent in a psychiatric hospital for an entire lifetime. If someone reaches that limit, original Medicare may cover further inpatient mental health care in a general hospital but not a psychiatric hospital. This rule only applies to free-standing psychiatric facilities that are not considered a part of general hospitals.

If you receive treatment for alcohol or substance abuse on an outpatient setting original Medicare Part B helps pay for outpatient substance abuse treatment services from a clinic or hospital outpatient department. Original Medicare will pay 60% of its approved amount for mental health services, and you or your Medicare insurance, such as your Medicare Supplement or Medicare Advantage plan, will be responsible for the remaining 40% of the costs of treatment on an outpatient basis.

What is covered by Medicare for alcohol and substance abuse treatment?

Covered services include, but are not limited to: Psychotherapy; patient education regarding diagnosis and treatment; post-hospitalization follow-up; prescription drugs administered during a hospital stay or injected at a doctor’s office; Methadone may be covered if provided to hospital inpatients but not provided in outpatient clinics. Outpatient prescription drugs would be covered under your Medicare Prescription Drug Plan (also known as “PDP” or “Part D”). Prescription Drug Plans must cover medically necessary drugs to treat drug abuse either through a formulary or through the exception process. Prescription Drug Plans cannot cover methadone to treat substance abuse, but can cover methadone for other conditions, such as pain.

Additional services covered by original Medicare include the following: Structured Assessment and Brief Intervention (SBIRT) services provided in a doctor’s office or outpatient hospital department. The Structured Assessment and Brief Intervention service is covered by original Medicare when an individual shows signs of drug abuse or dependency. The Structured Assessment and Brief Intervention services is a public health approach to treat substance abuse that involves:

  • Assessment to quickly determine the severity of substance use and identify the appropriate level of treatment.
  • Brief intervention or advice focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
  • Referral to treatment provides those identified as needing more extensive treatment with access to specialty care.

Medicare also covers a new preventive benefit that covers screening and counseling for people who show signs of alcohol or substance misuse but do not necessarily show signs of alcohol or substance abuse.

How is substance abuse covered if I have a Medicare Advantage Plan or Supplement?

If you have a Medicare supplement or Medicare Advantage (also known as “Part C”) plan, you should consult your Outline of Coverage or Summary of Benefits for more information on out-of-pocket costs for alcohol or substance abuse treatment counseling on both inpatient or outpatient basis. Co-insurances, co-pays or deductibles may apply for this type of treatment. You may also need to see in-network providers, according to your plan because if you see providers that are not in your plan’s network, charges will typically apply.

There again Medicare has you covered. If your New Year’s Resolution is to stop drinking or seek treatment for any type of substance abuse you now have one less excuse for not following through. Contact your doctor and schedule your initial assessment so you can begin your New Year’s Resolution as soon as possible. Medicare Pathways wants you to live a long, healthy and happy life. Take advantage of what Medicare has to offer to assist you in getting control of the things that have a bad effect on your life and your health. Medicare Pathways wishes you success with your resolution and the start to a healthier and happier new year


Stay Informed!  Visit our Medicare News Blog!

Medicare Pathways 1-866-466-9118