Medicare covers certain tests, services and programs that help in the treatment and recovery of mental health and substance abuse disorders. No, Medicare doesn't cover residential treatment programs for substance use disorders. Treatment for mental health and substance abuse disorders can be inpatient, outpatient, or residential, depending on the patient's circumstances and needs. Medicare may cover treatment for AUD and SUD.
The original Medicare and Medicare Advantage plans cover several treatment options, including hospital care, outpatient services, and prescription drugs, depending on the plan you choose. 1.This page provides basic information on how to become certified as a residential psychiatric treatment facility (PRTF) and includes links to applicable laws, regulations and compliance information. Medicare covers the treatment of alcoholism and substance use disorder in both inpatient and outpatient settings, including opioid treatment programs. Learn about eligibility, covered services, and how costs vary depending on the type of care you receive. Residential programs for the treatment of SUD are one step above partial hospitalization, but they are one step below hospital care.
Medicare Part A covers inpatient hospital care, palliative care, inpatient care in a skilled nursing facility, and home health care services. Depending on the outcome of that evaluation, Part B will also cover up to four primary care counseling sessions with a provider who accepts a Medicare allowance. As noted above, Medicare covers both inpatient and outpatient care (including intensive outpatient program services and partial hospitalization), starting in 2002, but the program does not cover residential treatment for SUD. Therefore, Medicare utilization management, coverage exclusions, and reimbursement rates may be stricter for treatment of SUD, which is not the case with Medicaid or most private health insurance plans.
You don't have to pay a deductible for inpatient rehabilitation care if Medicare already charged you a deductible for care you received in a previous hospitalization within the same benefit period. In 2024, new rules came into effect to ensure that Medicare beneficiaries have coverage for intensive outpatient programs1 and partial hospitalization services2, helping to address some important long-standing gaps in the coverage that Medicare provides to beneficiaries struggling with drug or alcohol addiction. Medicare Part A (hospital insurance) covers a variety of inpatient care in hospitals, skilled nursing facilities and critical access hospitals. In addition to annual wellness visits, Medicare covers a separate visit to further review a person's cognitive function, where the doctor checks for conditions such as dementia, depression, anxiety and other changes in mental health.
The patient lives in the residential facility for what can be an extended period of time, but does not need the level or intensity of care that would be provided during a hospital stay. To qualify for Medicare for disability, before turning 65, a person must have been eligible to receive Social Security Disability Insurance (SSDI) benefits for at least 24 months. Medicare Part A (hospital insurance) covers medically necessary care received at an inpatient rehabilitation center or unit (sometimes referred to as a “rehabilitation center,” IRF, intensive care rehabilitation center, or inpatient rehabilitation hospital). Under Medicare, a primary care doctor can evaluate a person's depression each year and refer them for further treatment.
Medicare's coverage of services for mental health, behavioral health and substance abuse disorders is not as comprehensive as coverage for other services services. With the many threats currently facing the Medicare program, now is the time to come together as partners and explore ways to advocate for comprehensive Medicare coverage, health equity and quality health care.
