Medicare Coverage for Alcohol & Substance Abuse

Medicare Coverage for Alcohol & Substance Abuse

Addiction doesn’t discriminate. It can take hold of individuals of any age, gender, or ethnicity, but if you are over the age of 65, you may be more likely to develop a smoking habit, misuse or abuse alcohol, or become addicted to prescription medication.

Seniors are at risk of dependence on smoking, alcohol, and drug for a variety of reasons: 

Generational Factors  

The generation older adults grew up in were not aware of the medical and scientific data we have today related to smoking, drinking, and drug use. People over the age of 65 might admit their now decades-long habit of smoking may have started before warning labels even appeared on cigarette cartons, and many of them may have grown up with their parents smoking or drinking frequently in the home. It can be difficult to overcome a habit or dependence that developed so many years ago.

Isolation and Depression  

Alcohol and substance abuse can result from depression and anxiety. Seniors are especially vulnerable to mental illness, and once they turn to alcohol or drugs, isolation may allow the situation to go unchecked and develop into addiction. Seniors who live alone and do not have family members or friends dropping by frequently can easily hide their dependence.

Age & Pain

Age can sometimes be accompanied by injury and illness that may result in chronic pain. Individuals over the age of 65 account for more than one-third of total outpatient spending on prescription medications in the United States.[1] In addition, almost one-third of all Medicare recipients (approximately 12 million people) were prescribed opiod painkillers in 2015.[2] The use of opiods can quickly turn into dependence and long-term addiction. Due to the slowing of kidney and liver function as we age, the amount of time opiod medications remain in your system can increase.

How Medicare Can Help

The Centers for Medicare & Medicaid Services provides a full range of services and treatments associated with alcohol and substance abuse disorders. Regardless of whether you receive Medicare due to age or disability, Medicare benefits include services to help with smoking cessation, alcohol addiction screening and substance abuse, with inpatient and outpatient treatment.  If you are eligible for Medicare, you can get help to overcome your addiction with little to no cost, as long as you visit providers that are approved by Medicare and accept assignment.

Smoking Cessation

Medicare Part B can help you quit smoking. Part B coverage includes up to 8 face-to-face visits with a counselor within a 12-month period of time, as long as the counseling is provided by a qualified doctor or other Medicare-approved provider. This includes two separate cessation attempts per year, each including 4 intermediate or intensive sessions. Intermediate sessions last anywhere from 3-10 minutes, and intensive sessions last more than 10 minutes.

Individuals with Medicare Part B who use tobacco are covered by this benefit, regardless of whether they exhibit signs or symptoms of tobacco-related disease. The recipient must be competent and alert at the time of counseling. Part B recipients will pay nothing for these services as long as their provider accepts assignment.

Over-the-counter treatments for smoking cessation, such as nicotine patches or gum, are not covered because over-the-counter medications are excluded from Medicare Part D. Prescription drugs for smoking cessation are covered under Medicare Part D (prescription drug benefit).

Alcohol Misuse

According to the Centers for Medicare & Medicaid Services(CMS), people who drink too much alcohol have a higher risk of injury, drowning, liver disease, and even some types of cancer. With this in mind, Medicare covers the cost of an annual alcohol misuse screening. If a primary care physician determines that a patient needs help in reducing or abstaining from alcohol consumption, they can get the help they need at no cost. 

Medicare recipients who screen positive for misuse, but do not meet the criteria for alcohol dependence based on levels or patterns of consumption, are eligible for 4 brief, face-to-face behavioral counseling interventions per year, as long as the Medicare recipient is competent and alert during the counseling sessions, which must take place in an approved primary care setting, such as a doctor’s office.

Medicare coinsurance and Part B deductibles are waived for these preventive services.

Alcohol Misuse vs. Dependence

How does an alcohol screening determine whether a patient is dependent on alcohol? If an individual’s alcohol use meets three of the following criteria, the primary care physician would consider the patient to be alcohol dependent, qualifying them for substance abuse benefits and treatment:

  • Tolerance
  • Withdrawal symptoms
  • Impaired control
  • Preoccupation with acquisition and/or use
  • Persistent desire and/or unsuccessful attempts to quit
  • Sustains social, occupational, or recreational disability
  • Use continues despite adverse consequences

 Alcohol and Substance Abuse

According to the Department of Health and Human Services (DHHS) and Centers for Medicare & Medicaid Services (CMS), substance abuse treatment services are covered by Medicare when deemed reasonable and necessary. These services can include inpatient or outpatient services for alcohol or drug dependence, with coverage and payment depending on the provider of the services on a case-by-case basis. 

What will Medicare cover for alcohol and substance abuse treatment?

Inpatient Services: Medicare Part A helps cover the cost of inpatient care if you are hospitalized for substance abuse treatment. (Methadone may be covered if provided to inpatient hospital patients but not provided in outpatient clinics.)

Outpatient Services: Medicare Part B helps cover the costs of outpatient services from a clinic or hospital outpatient department, including, but not limited to:

  • Psychotherapy
  • Patient education regarding diagnosis and treatment
  • Post-hospitalization follow-up
  • Prescription drugs administered during a hospital stay or injected in a doctor’s office

Outpatient Prescription Drugs: Part D plans must cover medically necessary drugs to treat drug abuse through their formulary or through the exception process. (Part D plans do not cover methadone to treat substance abuse, but can cover methadone for other conditions, such as pain.)

Medicare Coverage for Treatment

Keep in mind that if you are enrolled in a Medicare Advantage plan, you will have the same benefits offered by Original Medicare, but many offer additional benefits. If you are enrolled in a Medicare Advantage plan, contact your plan directly for more detailed coverage information.

[1] Misuse of prescription drugs; National Institute on Drug Abuse;

[2] America’s Addiction to Pain Pills, John Rosengren; June, 2017; AARP;

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