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
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.