Medicare covers a wide range of substance misuse treatments, including screening, counseling, interventions, and some prescription drugs. A person typically pays out-of-pocket expenses.
Medicare coverage for substance misuse is broad, as it includes a screening program, most medications, and inpatient and outpatient treatment.
Original Medicare, which includes Parts A and B, and Medicare Advantage, or Part C, provide coverage. However, patients must pay deductibles, copayments, and coinsurance.
This article discusses coverage for substance misuse treatment within each part of Medicare and out-of-pocket costs. It then looks at three interventions that Medicare includes in its coverage.
Glossary of Medicare terms
- Out-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and premiums.
- Premium: This is the amount of money someone pays each month for Medicare coverage.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
All parts of Medicare provide some coverage for substance use disorders.
Parts A and B coverage for substance misuse
Original Medicare comprises:
If a person with substance use disorder needs inpatient treatment in a general or psychiatric hospital, Part A covers the care. When an individual needs outpatient treatment, Part B provides coverage.
Part B coverage may include:
- a screening
- individual or group psychotherapy
- psychiatric assessment
- ongoing tests
- family counseling that relates to a treatment plan
- medication management
- prescription drugs that meet certain criteria
- diagnostic tests
- partial hospitalization
- intensive outpatient program services
Part C or Medicare Advantage coverage for substance misuse
Part C, or Medicare Advantage, is the alternative to Original Medicare.
It covers parts A and B benefits for the treatment of substance use disorder, but a person with a plan may need to use in-network providers.
Medicare Part D provides prescription drug coverage, which a person with Original Medicare may purchase.
The plans include coverage of medications that doctors consider medically necessary for the treatment of opioid dependence.
Transition policy
Medicare requires Part D plans to have a transition policy.
If a person recently signed up for a Part D prescription drug plan, coverage may be delayed until the new policy takes effect.
If a person has an opioid dependence, the transition policy allows them to get their prescribed drugs quickly and without delay.
Does Medicare cover methadone or suboxone?
Part D may cover methadone when used to treat pain but not when used to treat substance misuse. It may also cover suboxone.
Part A covers methadone when a doctor prescribes it during a hospital stay. Medicare Part B may pay for methadone when prescribed in an inpatient setting.
Does Medicare pay for oxycodone?
Medicare Part D might cover opioid pain medications like hydrocodone (Vicodin), oxycodone (OxyContin), morphine, codeine, and fentanyl to help alleviate your symptoms. However, the medications covered will vary based on your specific plan.
Opioid safety notice
Opioids are highly effective pain medications. However, it’s important to know that they do have the potential for addiction and misuse.
There are a few steps a person can take for safer opioid use:
- Tell a doctor about any history of substance misuse so they can carefully monitor the medication regimen.
- Follow the directions listed on the prescription. Taking too much or taking a dose incorrectly, such as crushing pills before taking them, may lead to serious side effects, including difficulty breathing or overdose.
- Speak with a doctor about what substances to avoid while taking opioids. Mixing opioids with alcohol, antihistamines (such as diphenhydramine), benzodiazepines (such as Xanax or Valium), muscle relaxants (such as Soma or Flexeril), or sleep aids (such as Ambien or Lunesta) can increase the risk of dangerously slowed breathing.
- Store medications in a secure place and out of reach of children and take any unused pills to a community drug take-back program for disposal.
In outpatient settings, Medicare covers a program called Screening, Brief Intervention, and Referral to Treatment (SBIRT).
This is an early intervention approach that aims to prevent a person with non-dependent substance use from developing a substance use disorder.
The SBIRT program has the following components:
- screening for potential substance misuse
- a brief intervention to increase a person’s awareness of their substance use and to encourage a change in behavior
- referral for additional treatment, if needed
Original Medicare and Medicare Advantage cover treatment programs for people with opioid use disorder. The coverage includes:
- medications approved by the Food and Drug Administration (FDA) for the disorder
- counseling
- individual or group therapy
- intake activities
- toxicology testing
- periodic evaluations
- intensive outpatient program services
If a person has Original Medicare and is treated as an outpatient, this program is free, except for the Part B deductible of $257 in 2025.
Individuals with a Medicare Advantage plan may have to pay a copayment. It would be useful to ensure that a person’s opioid treatment provider is enrolled in Medicare.
Partial hospitalization
Medicare Part B also covers partial hospitalization, which is another form of treatment for substance use disorder. It sometimes serves as an alternative to inpatient care.
The treatment consists of intense outpatient psychiatric sessions that a person receives during the daytime.
The program does not require an overnight stay.
Services that someone may have during partial hospitalization include:
- psychotherapy
- occupational therapy
- self-administered prescribed medication
- personalized activity therapy
- family counseling
inpatient rehab
Medicare Part A covers necessary inpatient rehabilitation as long as a doctor confirms a person’s need for intensive rehab and medical supervision. This includes rehabilitation for substance misuse. The treatment includes:
- necessary treatment services
- a semiprivate room
- meals
- nursing services
- prescription medications
- other hospital services and supplies
While Medicare offers broad coverage for rehabilitation and substance misuse treatment, it does not cover every service, such as:
- private duty nursing
- support groups for substance use disorder
- transportation to mental health care services
Part A out-of-pocket costs in 2025 include:
- 20% coinsurance for mental health services received in a hospital
- $1,676 deductible for each benefit period
- 0% hospitalization coinsurance for the first 60 days of each benefit period
- $419 hospitalization coinsurance for days 61 to 90 of each benefit period
- $838 per ‘lifetime reserve day.’ A person has 60 lifetime reserve days, which they can use after day 91 of a hospital stay.
A benefit period starts the day a person enters the hospital and ends the day they have been home from the hospital for 60 consecutive days.
Part B out-of-pocket costs in 2025 include:
- $185 monthly premium
- $257 annual deductible
- 20% coinsurance
If a person is enrolled in the partial hospitalization program, they may have to pay an additional coinsurance to the hospital.
Parts C and D out-of-pocket costs vary among plans.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Medicare covers the SBIRT program, which is an early intervention screening and prevention program designed to help people at risk of substance use disorder.
After a person receives a diagnosis of a substance use disorder, Original Medicare covers both inpatient and outpatient substance misuse treatment that a doctor considers medically necessary. This includes some prescription drugs.
People with Original Medicare may wish to purchase Part D, which covers prescription drugs.
Medicare Advantage plans cover the same benefits as Original Medicare and usually include Part D medication coverage.
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