CHAMP HELPLINE: 888-614-5400
CHAMP HELPLINE: 888-614-5400

Medicare for Mental Health and Substance Use Disorder

This guide will provide some basic information about Medicare health insurance. If you or someone you know has questions about how health insurance works for mental health or substance use disorder call our free helpline at 888-614-5400

What is Medicare?

 

Medicare is a federal health insurance program for people 65 years and older and some younger people with disabilities.

People who use Medicare have two options for how to get their benefits:

  • Original MedicareThe traditional program offered directly through the federal government
  • Medicare AdvantagePrivate plans that contract with the federal government to provide Medicare benefits

Medicare Advantage plans must cover base line care standards as written in the law. However, Medicare Advantage Plans may have more limited provider networks for each type of care or treatment. It is always important to compare plans before signing up for one to make sure it meets your needs. CHAMP can help you compare your coverage options.

What Does Medicare Cover?

 

Mental Health
  • InpatientInpatient behavioral health services received in psychiatric hospital (hospital or distinct unit in hospital that only treats mental health patients) or a general hospital. If you receive care in a psychiatric hospital, Medicare covers up to 190 days of inpatient care in your lifetime. Residential treatment is not covered.
  • OutpatientOutpatient mental health care, including individual and group therapy, partial hospitalization programs, and annual depression screenings in primary care settings.
  • PrescriptionPrescription drugs, including many drugs used to treat mental health conditions.
Substance Use Disorder
  • InpatientMedically necessary inpatient care at Medicare-approved facilities, including inpatient detoxification. Residential treatment is not covered.
  • OutpatientSubstance use disorder care at Medicare-certified clinics, opioid treatment programs, or hospital outpatient departments, and sometimes via telehealth.
  • PrescriptionMedications used to treat substance use disorder may be covered by your Medicare Part D drug plan as outpatient prescription drugs (like suboxone or buprenorphine) or as part of care you receive at a Medicare-certified clinic, opioid treatment program, or hospital (like methadone or Vivitrol).

* Medications that must be administered by a health care provider, like methadone and Vivitrol, are covered under Medicare Part B (if administered in an outpatient setting) or Medicare Part A (if administered as part of an inpatient hospital stay), rather than under Medicare Part D drug plans

Tips To Accessing Care

 

  1. Learn if a service is covered
    • If you have Original Medicare:
      • Call 1-800-MEDICARE (1-800-633-4227).
      • Look up your service on medicare.gov/coverage.
      • Speak with your doctor.
    • If you have a Medicare Advantage or Part D plan:
      • Call your plan. There should be a customer service number on the back of your plan card.
      • Read the coverage booklet from your plan.
      • Use any online tools that your plan provides.
  2. See a Medicare-approved provider

    Always check that any service providers are Medicare-certified and charge the Medicare-approved amount. You have the lowest out-of-pocket costs when you see these providers.

    Some providers choose to opt out of Medicare. Some providers and facilities that treat substance use disorder are not able to be certified by Medicare. If you see an opt-out provider, you will be responsible for the full cost of your care.

    CHAMP can help you find a provider or file a complaint if you cannot find one. Just call 888-614-5400.

    You can also file a complaint against your plan by calling 1-800-MEDICARE.

  3. Clearly communicate with your doctor

    Sometimes a provider may not be familiar with all of Medicare’s coverage rules. They may say something is not covered or bill the wrong part of Medicare for the treatment.

    This can happen with treatment for substance use disorder, like when a person gets a medication injected at the doctor’s office or dispensed by an opioid treatment program. Medicare covers these medications, like methadone, Sublocade and Vivitrol, as part of your treatment. Your provider must bill the right part of Medicare

    For these types of things, make sure your provider bills Medicare Part B or the health coverage part of your Medicare Advantage Plan for these services.

    If your provider has other questions about coverage rules or how to bill for a service, tell them to contact their Medicare Administrative Contractor (MAC) or your Medicare Advantage or Medicare Part D plan.

  4. Know how to access medication at the pharmacy

    Sometimes you may go to the pharmacy and learn that you cannot access your medication. For help you call 888-614-5400 to speak with a CHAMP counselor. You can also try the following tips, depending on your situation.

    If your medication is covered but too expensive, contact your doctor. See if there is a less expensive alternative you can take. Your doctor may also be able to help you ask the plan to put the medication on a lower cost tier.

    If your medication is not covered, contact your plan to learn why. Once you have the denial reason, contact your doctor for help filing an appeal.

     If your pharmacy cannot provide the medication, see if your pharmacist can help. Certain medications, like opioids, may have an added safety check at the pharmacy. The pharmacist may be able to get rid of the safety check. If your pharmacist cannot help, contact your doctor