What is Medicare?
Medicare is the national health insurance program to which all Social Security recipients who are either over 65 years of age or permanently disabled are eligible. In addition, individuals receiving railroad retirement benefits and individuals living with end stage renal disease are eligible to receive Medicare benefits.
Medicare for People with Disabilities
To qualify for Medicare by virtue of disability, before the age of 65, a person must have been eligible for Social Security Disability Insurance (SSDI) benefits for at least 24 months. The first 24 months is the waiting period for Medicare coverage. If the person returns to work, they can get up to 93 more months of premium-free hospital and medical insurance after the trial work period as long as they still have a disabling impairment. After the premium-free coverage ends, beneficiaries can purchase Medicare hospital and medical insurance if they continue to have a disability, but premiums can be prohibitively expensive.[1]
Medicare Versus Medicaid
“Medicare” is often confused with “Medicaid” – and some are eligible for both – but these are very different programs. Medicaid is an income-based program that is funded by the federal government but administered by individual states, and eligibility and coverage rules can vary greatly by state. A person’s income and assets are not a consideration for Medicare eligibility or benefit payment – though they can affect some cost-sharing. Medicare is a national program and rules should not vary significantly from state to state for those in the traditional program. Medicare coverage is similar to that provided by private insurance companies: it pays a portion of the cost of medical care. Generally, deductibles and co-insurance – which are partial payment of initial and subsequent costs – are required of the person receiving services.
The ”Parts” of Medicare
Medicare has three substantive coverage components, Part A, Part B and Part D. Medicare Part A covers inpatient hospital care, hospice care, inpatient care in a skilled nursing facility, and home health care services. Part B covers medical care and services provided by doctors and other medical practitioners, durable medical equipment, and some outpatient care and home health services. Part D is prescription drug coverage, which was added to Medicare in 2006. Medicare drug coverage is only available through private plans – either a stand-alone Part D plan, or a private “Medicare Advantage” plan, discussed below.
Part A of the program is financed largely through federal payroll taxes paid into Social Security by employers and employees. Part B is financed by monthly premiums paid by Medicare beneficiaries and by general revenues from the federal government. In addition, Medicare beneficiaries themselves share the cost of the program through copayments and deductibles that are required for many of the services covered under both Parts A and B.
Medicare Part C, the missing letter from the list above, is a bit different. An increasing number of beneficiaries (over 30 million nationwide)[2] are receiving Medicare services through private, for-profit managed care plans. This is what Medicare Part C refers to – Medicare managed care. As noted above, Medicare managed care is currently referred to as “Medicare Advantage” or “MA” While it is different from the traditional Medicare program, by law MA plans must have coverage that is at least as good as that of traditional Medicare. In practice, however, receiving that coverage is often more difficult, as MA plans often have limited provider networks, use strict requirements for coverage like Prior Authorization, and can terminate providers from their networks at will.
Medicare Coverage of Alcohol and Substance Use Disorders
Medicare covers certain screenings, services, and programs that aid in the treatment and recovery of mental health and substance use disorders (SUD):[3]
- Alcohol misuse screenings – Free once per year from primary care provider for those who don’t meet the criteria for dependency.
- Counseling to prevent tobacco use & tobacco-caused disease – Medicare Part B covers up to 8 smoking and tobacco-use cessation counseling sessions in a 12-month period.
- Opioid use disorder treatment services[4] – Medicare covers treatment received from an opioid treatment program provider who’s enrolled in Medicare and meets other requirements at no cost, EXCEPT in Medicare Advantage, as plans are allowed to charge a co-pay. The Part B deductible also still applies for supplies and medications you get through an opioid treatment program provider. Coverage includes:
- Approved medication-assisted treatment;
- Substance use counseling you get in person or virtually;
- Individual and group therapy you get in person or virtually;
- Toxicology testing; Intake activities;
- Periodic assessments you get in person or virtually
- Opioid antagonist medications (like naloxone) approved for the emergency treatment of known or suspected opioid overdose;
- Overdose education you get along with opioid antagonist medication.
- Behavioral health integration services – For conditions including Depression, anxiety and more, Medicare may pay your provider to help manage the condition. You pay a monthly fee and part B cost-sharing applies.
Medicare Coverage of Mental Health Care
- Inpatient – Part A covers services for those admitted as a hospital inpatient, but Part B covers services received from other providers while in the hospital. In 2024 there is a $1632.00 deductible. Days 1-60 are free, days 61-90 have a $408.00 co-pay per day. There are 60 “lifetime reserve days” after 90 days, at $816.00 per day. After those, nothing is covered for the stay. There’s no limit to the number of benefit periods you can have, whether you’re getting mental health care in a general or psychiatric hospital. However, importantly, if you’re in a psychiatric hospital (instead of a general hospital), Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime.[5]
- Outpatient[6] – Medicare pays for outpatient substance use disorder treatment as described above. In addition, it will cover:
- One free depression screening per year in a primary care doctor’s office or primary care clinic.
- Individual and group psychotherapy.
- Family counseling if the main purpose is to help with your treatment.
- Testing to verify services are needed and effective.
- Psychiatric evaluation.
- Medication management.
- Certain prescription drugs that aren’t generally drugs you would take on your own, like some injections.
- Diagnostic tests.
- Partial hospitalization.
- A one-time “Welcome to Medicare” preventive visit. This visit includes a review of your possible risk factors for depression.
- A yearly “Wellness” visit. Talk to your doctor or other health care provider about changes in your mental health since your last visit.
- Starting January 1, 2024 – Intensive outpatient program services
- In traditional Medicare, costs for services other than depression screening will be 20% of whatever amount Medicare decided for the cost of that service (the “Medicare Approved Amount”) after the full Part B deductible has been met.
- Partial hospitalization[7] – A structured program of outpatient services as an alternative to inpatient psychiatric care, with no overnight stays needed, Medicare helps cover partial hospitalization services you get through a hospital outpatient department or community mental health center. You pay a percentage of the Medicare-approved amount for each service. After the Part B deductible is met, there is also coinsurance for each day of partial hospitalization services you get.
- Intensive outpatient services – As of January 2024, Medicare Part B covers intensive outpatient program services you get at a hospital, community mental health center, Federally Qualified Heath Center, or Rural Health Clinic. These services are “a level of mental health care between traditional once-weekly therapy or counseling, and inpatient psychiatric care.”[8] Services may include group and individual therapy sessions. As with partial hospitalization, you pay a percentage of the Medicare-approved amount for each service, and once the Part B deductible is met, there is also coinsurance for each day of intensive outpatient program services you get.
- Telehealth[9] –Telehealth services at any location in the U.S., including your home are available for services to treat a substance use disorder or a co-occurring mental health disorder (sometimes called a “dual disorder”), or for the diagnosis, evaluation or treatment of a mental health disorder.
We Know this Coverage Could Be Better
An estimated 1.7 million[10] Medicare beneficiaries are living with a diagnosed substance use disorder (SUD) and 1 in 4[11] Medicare beneficiaries are living with a mental health condition. While Medicare covers a broad array of treatment services for those with mental illness and substance abuse disorders, special rules limit coverage and reimbursement. Medicare’s coverage of services for mental health, behavioral health and substance abuse disorders is not as extensive as its coverage for other services. Medicare does not cover the full continuum of services recognized by the American Society of Addiction Medicine, nor the range of providers and settings needed for effective, evidence-based treatment. Medicare is not subject to the Mental Health Parity and Addiction Equity Act (Parity Act), which protects people with SUD and mental health conditions from insurance inequities. As a result, millions of Americans who depend on Medicare are unable to receive the life-saving treatment they need and deserve.
In 2022 the Center for Medicare Advocacy along with partners Legal Action Center and Medicare Rights Center released a set of principles to guide expansions in Medicare coverage.[12] The principles would apply the Parity Act to Medicare Parts A, B, C and D, authorize coverage of the full continuum of evidence-based SUD treatment services, authorize coverage of community-based SUD treatment settings, authorize coverage of all licensed and certified mental health and SUD treatment providers, and establish adequate reimbursement rates.
Additional Resources for Information and Assistance
National Institute of Mental Health (NIMH), National Institutes of Health (NIH)
Visit nimh.nih.gov.
Call 1-866-615-6464. TTY users can call 1-301-443-8431.
Email nimhinfo@nih.gov.
Substance Abuse and Mental Health Services Administration (SAMHSA)
Visit samhsa.gov. To find treatment facilities in your area, visit findtreatment.samhsa.gov.
Call 1-877-SAMHSA-7 (1-877-726-4727). TTY users can call 1-800-487-4889.
Mental Health America
Visit mhanational.org.
Call 1-800-969-6642.
National Alliance on Mental Illness (NAMI)
Visit nami.org.
Call or text the Information Helpline at 1-800-950-NAMI (1-800-950-6264).
National Council for Mental Wellbeing
Visit thenationalcouncil.org.
Call 1-202-684-7457.
Email Communications@thenationalcouncil.org.
Legal Action Center
visit https://www.lac.org
Call (212) 243-1313 or email lacinfo@lac.org
Start Your recovery
StartYourRecovery.org
Faces and Voices of Recovery
https://facesandvoicesofrecovery.org
CT Community for Addiction Recovery (CCAR)
https://ccar.us
References: (All links visited 1/2024)
[1] https://www.ssa.gov/disabilityresearch/wi/medicare.htm
[2] https://www.kff.org/medicare/issue-brief/a-snapshot-of-sources-of-coverage-among-medicare-beneficiaries/
[3] https://www.medicare.gov/coverage/mental-health-substance-use-disorder-services
[4] https://www.medicare.gov/publications/12085-Opioid-Treatment-Programs.pdf
[5] https://www.medicare.gov/coverage/mental-health-care-inpatient
[6] https://www.medicare.gov/coverage/mental-health-care-outpatient
[7] https://www.medicare.gov/coverage/mental-health-care-partial-hospitalization
[8] https://www.medicare.gov/coverage/mental-health-care-intensive-outpatient-program-services
[9] https://www.medicare.gov/coverage/telehealth
[10] https://pubmed.ncbi.nlm.nih.gov/35331570/
[11] https://www.commonwealthfund.org/publications/issue-briefs/2020/jul/medicare-mental-health-coverage-covid-19-gaps-opportunities
[12] https://medicareadvocacy.org/wp-content/uploads/2022/07/Principles-of-Medicare-Parity.pdf