Rehab and Medicare: The Ultimate Guide to Addiction Treatment for Seniors with Medicare

Overview

The senior population, those 65 and older, is booming, and according to the U.S. Census Bureau is set to reach 83.7 million by 2050, nearly double the population of that age group in 2012.

Sadly, senior citizens are especially susceptible to alcohol and drug abuse. In fact, according to the Institute of Medicine, 1 in 5 people 65 or older have one or more mental health or substance abuse conditions.

As a December 2014 Dallas Morning News article explains, there are a couple of reasons for the prevalence of addiction in this age group:

  1. Compared to other generations, Baby Boomers were more likely to be exposed to substance use as they “came of age.”
  2. It is a reaction to factors such as loneliness and depression that can come with old age.

Unfortunately, confusion often exists around the role Medicare can play in covering the costs of addiction recovery for seniors. Following is a resource guide for the elderly who are seeking information on how they can get treatment through Medicare.

Are You Addicted? Signs You Have a Problem Checklist

  • Are you taking more than your prescribed dosage?
  • Are you mixing your prescription medicines with alcohol?
  • Are you drinking more than 3-4 drinks per day?
  • Are you having trouble sleeping or sleeping more during the day?
  • Have you visited multiple doctors to get prescribed the same medication?
  • Are you having trouble balancing?
  • Are you having memory problems?

Are you taking more of than your prescribed dosage? As Family Doctor explains, the elderly often take more prescribed drugs than other populations and therefore are at greater risk of abusing the medicines. If you’re running out of your prescription more quickly than usual, taking it more frequently, or taking more than the prescribed dosage, it is possible that you are abusing your prescription, and you should seek help.

Are you mixing your prescription medicines with alcohol? The National Council on Alcoholism and Drug Dependence notes that a common sign of prescription drug abuse among seniors is mixing drugs that shouldn’t be taken together and/or taking pills with alcohol.

Are you drinking more than 3-4 drinks per day? According to the National Institute on Alcohol Abuse and Alcoholism, women who drink more than 3 drinks per day or men who drink more than 4 drinks per day may be at risk for an Alcohol Use Disorder (AUD).

Are you having trouble sleeping or sleeping more during the day? Health in Aging notes that changes in sleep patterns in an older person are an early sign of prescription drug misuse or alcohol abuse.

Have you visited multiple doctors to get prescribed the same medication? The National Institutes of Health’s website for seniors explains that “doctor shopping” in order to get several of the same prescription is a sign of substance abuse and dependency. 

Are you having trouble balancing? If you’re having balance issues or have fallen recently, the American Osteopathic Association says drug or alcohol abuse could be contributing to these issues.

Are you having memory problems? Often, signs that an elderly person is abusing drugs or alcohol are simply attributed to old age. However, the New York State Office of Alcoholism and Substance Abuse Services notes that sometimes certain issues, such as trouble remembering, are being caused by substance abuse.

Medicare Coverage Factors to Consider

What kind of Medicare do you have? Before seeking treatment, it is important that you understand what coverage you receive. You can check your enrollment. Most users are covered by Original Medicare, but some are covered by Medicare Advantage, a type of private health plan.

Do you have Medigap and what will it cover? Medigap is supplemental insurance sold through a private company that covers the gaps in coverage that exist with Medicare. Medicare Matters explains these coverage gaps and how Medigap works.

Do you need inpatient or outpatient treatment? Your plan will cover both inpatient and outpatient addiction treatment. Inpatient treatment is covered by Part A and outpatient treatment is covered by Part B up to 80 percent.

Do you meet the criteria for coverage? As this article from LiveStrong notes, certain criteria must be met in order for your inpatient drug addiction treatment to be covered:

  • The treatment facility must participate in Medicare.
  • Your doctor must indicate that it is “medically necessary” and create a treatment plan.
  • Medicare must agree that the it is reasonable and necessary.

How do you find a facility that accepts Medicare? The Substance Abuse and Mental Health Services Administration provides a Treatment Services Locator. Type in your City, State or zipcode to see a map of the facilities in your area. The facilities will also be listed on the right-hand side of your screen. Click on “More Information” to find out if a specific facility accepts Medicare.

What isn’t covered? This Coverage Summary explains Medicare’s “limitations and exclusions.” For example, the program won’t pay for procedures or drugs that are still being studied.

What should you do if your addiction treatment is denied? According to the Center for Medicare Advocacy, lack of direct supervision by a doctor is one common reason addiction treatment claims are denied. You can appeal these decisions. The AARP provides information on how to do so.

Tips for Navigating the Medicare System

Ask ahead of time if your treatment will be covered. LoveToKnow.com suggests checking that your treatment will be covered before you begin it. You can do so by calling 1-800-MEDICARE.

Understand what “reasonable and necessary” means. As an article from The New England Journal of Medicine notes, the “reasonable and necessary” clause has been part of the Medicare policy since it began in 1965. It takes a look at how the Centers for Medicare and Medicaid Services define “reasonable” and “necessary,” respectively, and educates readers about possible discrepancies.

Know that certain facilities aren’t covered. Medicare has specific requirements for the kinds of medical organizations it will approve for addiction recovery. AddictionBlog advises that detox clinics or other facilities that aren’t connected to a general or psychiatric hospital may not be covered.

Know that if you’re not covered by Medicare, you can get covered. If you are 65 or older, you will be automatically enrolled. However, if you are younger than 65, it is possible to get coverage if you meet certain criteria. Contact the Social Security Administration to find out if you are eligible.

Be aware of the psychiatric hospital limit. The National Association of Psychiatric Health Systems explains that Medicare still enforces a 190-day lifetime limit on inpatient psychiatric care. The limit applies to stays at psychiatric facilities that are not connected to general hospitals.

Take advantage of preventive screening. As this informational piece from CMS explains, Screening, Brief Intervention, and Referral to Treatment Services (SBIRT) are covered. The program acts as a preventive method for catching alcohol and drug abuse in its early stages.

Seek treatment facilities with programs for seniors. When seeking an addiction recovery program, it’s important that you find one whose staff includes physicians, registered nurses, psychiatrists, counselors, and other medical professionals who understand the specific recovery needs that come with geriatric care.

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