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.

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11 Comments So Far. Add Your Wisdom.

5 days ago

We have been trying to find a detox and inpatient treatment facility for our 68 yr old Mama. She has Meicaid plan b with a supplemental insurance. Why is this so difficult? Grateful for any recommendations. This is life or death for her :(

21 days ago

if you are a veteran, they have a methadone treatment program at your nearest VA hospital.

24 days ago

I am turning 65 this month. Up til now my methadone o/p clinic has been paid by Med-i-cal in California. Medicare wont pay for the clinic. So its $300 a month now to continue with methadone maintenence. That needs to change. Its really a hardship on senior citizens who have been on the program for quite awhile. The program is a lifesaver for addicts. Please make it available through Medicare.

27 days ago

Thanks for sharing best information regarding Methadone Treatment Program.I will really join it.

6 months ago

I'm part of a methadone o/p program and my Medicaid was recently cut off. Now, they want me to pay a spend down and I can't afford it. I live in NYC and my SSD barely covers my living expenses. I want to transfer to o/p suboxone program, will Medicare cover it? I've found some information that said it might. Can anyonecconfirm it, or offer me some information, please?

over 1 year ago

Looking for Dual Diagnosis treatment, I have healthsring-only 37, on dissability I take suboxone for pain and opiate addiction and have for the last year and its workibg great, need help wiyk benzo's and stress. In the Birmingham area or surrouding areas. an suggestions?

Anonymous said over 1 year ago

69 year old need a facility for Alcohol treatment that could be cover at least in part by medicare or medicaid

over 1 year ago

My Medicaid plan covered my outpatient methadone maintenance fees. Now that I turned 65, my program does not cover me. What's up? Can I be saved?

over 2 years ago

I am,a recovering Alcholiic and addicted to pain meds I need a treatment plan that offer medical detox and recovey treatment. I have Medicare part a & B with supplement coverage with Anthem Blue Cross

almost 4 years ago

I have had a prescription drug addiction relapse after 11 yrs of sobriety (26 yrs for alcohol. I am looking for a therapist who accepts Medicare part B (my doctor does not. I am 67 yrs old and work part-time.

over 4 years ago

who are medicate approved providers for alcohol outpatient care in portland oregon


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