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While it won’t make treatment totally free, Medicare will cover the majority of substance abuse treatment costs.
Inpatient care is slightly more complex, with more cutoffs for aid.
Navigating insurance is rarely easy or enjoyable. Willfully or not, some policies seem to be built to obfuscate what they do and do not cover.
Generally speaking, Medicare will cover treatment for substance abuse.
Medicare is a program funded by U.S. taxpayers. In short, it is a health insurance program a citizen or permanent resident pay into throughout their life and then benefits from once one of a few conditions are met.
If you have questions about Medicare, such as whether you qualify or whether a particular treatment will be covered, numerous resources are available online. For example, the U.S. Centers for Medicare & Medicaid Services (CMS) have set up a free site to help people navigate the program, with links to details on its various parts.
Medicare Parts A and B are especially relevant to rehab services. They provide at least some way to get quality drug coverage.
In an information sheet intended for health care providers and suppliers, CMS gives an overview of the types of substance abuse treatment Medicare is able to cover.
While not all of the information provided is relevant for a patient, it establishes that Medicare will generally cover any drug rehabilitation that is medically necessary. Programs meant to promote socialization or marketable skills are likely not covered.
Medicare generally categorizes substance abuse treatment as a mental health treatment. This type of care is then categorized further into three broad treatment groups:
While there are complexities to all these programs, a basic rule of thumb is that once you pay your deductible, you will mostly be paying for 20 percent of the costs of Medicare-approved treatments and whatever amount for prescription drugs is relevant to your specific plan.
The primary exception relevant to substance abuse treatment is inpatient care.
The first necessary thing is to understand what a “benefit period” is. Essentially, this period begins when you are admitted as an inpatient, and it ends when you are out of the hospital for 60 days in a row. With this in mind:
Once a benefit period is over, and if a new one begins, this cycle resets, with the exception of spent lifetime reserve days. You will again have 60 more days of inpatient care with no coinsurance payment and so on.
There is one quite controversial element of Medicare to also keep in mind. Medicare has a lifetime inpatient care cap of 190 days for care at psychiatric hospitals. For some people, this may be a major obstacle to receiving the treatment they need, especially if they struggle with another serious mental illness in addition to their struggles with drug dependence.
Discuss the nature of any treatment with a health care professional if you are worried about coverage. They will have insights into the specifics of their program as it relates to health insurance.
CMS notes that sometimes a recommended treatment or length of treatment may end up not being covered. It is important to understand your options in this scenario and to keep you, and your health care provider informed.
Many people have both Medicare and another form of insurance. While the exact mechanics of this can be a bit complex, the two insurance plans are essentially categorized as either the “primary payer” and the “secondary payer.” In rare cases, there may be a third payer for people covered by several insurance plans.
To find out who the primary payer is, call the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627.
Basically, the primary payer pays whatever they usually cover. The remaining costs go to the secondary payer. Exactly how much the patient pays depends entirely on the nature of the plan working in conjunction with Medicare. A secondary plan does not guarantee that the patient will have no costs.
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