Medicare Coverage of Outpatient Substance Abuse Treatment

What It Is

Alcohol or drug abuse treatment provided on an outpatient basis, in an office, clinic, or hospital outpatient department

What's Covered

Medicare Part B covers outpatient alcohol or drug abuse treatment under certain circumstances, from Medicare-approved providers.

Medicare Part B covers diagnosis, establishment of a treatment plan, and follow-up care from a physician for alcohol or drug abuse. Medicare Part B doesn't cover outpatient prescription drugs related to alcohol or drug abuse treatment.

If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B plans.) To find out whether your plan provides extra coverage or requires different co-payments for outpatient substance abuse treatment, contact the plan directly.

If you have a Medicare Part D prescription drug plan: Your Medicare Part D prescription drug plan may cover a medicine prescribed by a doctor as part of alcohol or drug abuse treatment. To find out if the specific medicine prescribed for you is covered by your Medicare Part D plan and, if so, how much your co-payment would be, contact the plan directly.

If provided as part of a comprehensive treatment plan established by the patient's doctor, Medicare Part B covers alcohol or drug abuse therapy (individual and/or group) by a psychotherapist, clinical psychologists, clinical social workers, nurse practitioners or nurse specialists, or other state-licensed alcohol abuse health workers. Medicare Part B covers this treatment in an office, clinic, or hospital outpatient department.

What Medicare Pays

Medicare Part B pays 80 percent of the Medicare-approved amount for the services of a treating physician.

Medicare Part B pays 50 percent of the Medicare-approved amount for other outpatient alcohol or drug abuse treatment services. If services are provided by a clinic or hospital outpatient department, there may also be an additional patient co-payment.

Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:

• The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?

• The care must be performed or delivered by a healthcare provider who participates in Medicare.