Will Medicare cover my addiction treatment?

In this week’s column, Phil Moeller, the author of Get What’s Yours for Medicare: Maximize Your Coverage, Minimize Your Costs and co-author of the updated edition of How to Get What’s Yours: The Revised Secrets to Maxing Out Your Social Security, covers Medicare’s policy on addiction treatment.

Does Medicare offer coverage options for my addiction treatment?

Anonymous – Pennsylvania: I am 42, have three children, and am receiving Social Security disability benefits. I also have become addicted to Xanax, which has been prescribed to me in high doses. I wish the doctors would tell you how badly these medications mess with your mind! Despite my need for help, Medicare has denied me coverage for the rehabilitation help that I need.

Fortunately, I am about to get remarried to a wonderful man who has employer insurance that will cover the care I need. But here’s the rub. The rehab services we’ve contacted say that even though my new employer plan will provide primary coverage, they will send this claim to Medicare anyway, and it will once again be denied. The rehab people are thus telling me to drop Medicare.

I called the agency and was told I can drop Medicare without threatening my disability benefits. However, if I do cancel Part B, I will face big re-enrollment penalties if I again need Medicare before turning 65. That’s a long way off, and who knows what my health insurance needs will be over the next 20 years?

I just keep hitting roadblock after roadblock with Medicare. I am sure I am not the only person is this situation. I have been calling rehabilitation centers for years in state and out of state and no one will help me. I have even been kicked out of hospitals because they say there is no help for me there! This is so frustrating for people who really want help.

Phil Moeller: Unfortunately, you have lots of company here. Xanax is a powerful benzodiazepine drug prescribed for anxiety and depression; others include Ativan, Dalmane, Halcion, Librium, Restoril, Rivotril, Serax, Valium, and Versed, according to Pennsylvania state prescribing guidelines. Addiction to these drugs is a serious and growing problem.

In Pennsylvania, 46 prescriptions for “benzos,” as they’re widely known, were issued for every 100 adults in the state in 2012, according to the Centers for Disease Control and Prevention. As alarming as that number may appear, a dozen other states had even higher prescription rates. Further, overdose death rates from these powerful drugs have increased 500% during the past 20 years, a trend that appears to have worsened as use of the drugs became more widespread.

In terms of whether Medicare will cover your treatment, the key variable is whether such care is prescribed as medically necessary, according to Patrice Muchowski, head of clinical services as AdCare Hospital, which operates treatment centers in Massachusetts and Rhode Island and is part of the larger, nationwide American Addiction Centers network.

Medicare will cover addiction treatment that doctors and other licensed caregivers think is medically necessary. If your doctors went through the proper steps, it’s likely that Medicare would cover your care, she said. But she said it’s not clear from what you described exactly what steps you and your doctor already have taken.

Odds are, however, that showing up at a hospital with your Medicare card is not going to get you the covered care you seek. Benzos are very powerful, she stressed, and the best way to come off of them is through “a very, very, very slow taper (program), done either by a physician prescribing it” or a hospital familiar with such treatments.

Not all hospitals are equipped to provide that treatment, but ask for a “level 4” facility, Muchowski advised. This is rated as the highest level of addiction care by the American Society of Addiction Medicine.

Muchowski had these four additional suggestions, while emphasizing that she would need to know much more about your situation to provide informed guidance:

• Not all drug rehabilitation facilities accept Medicare, so make sure you’re talking with one that does.
• A psychiatric facility might be worth pursuing, as they usually take Medicare. The American Academy of Addiction Psychiatry has a referral service.
• Speak to the person prescribing your Xanax to discuss outpatient programs that can provide you professional help in tapering off this drug. Your prescriber has the right to lower the dosage as well, which could be part of a formal tapering program.
• Your fiance’s employer might have a formal employee assistance program that can help you.

I’m sorry things have been so hard. It’s bad enough being ill without getting messed up by the system that’s supposed to help. Of course, I do not know why Medicare does many of the things it does, but in this situation, it doesn’t appear to me that Medicare is “the bad guy.”

I do know that you should be able to keep Medicare and that doing so should not conflict with your new employer plan. They should work together. The benefits people at the employee plan should be able to help there.

I also know that you can drop Medicare and later get it again with no problems or penalties, so long as you have had coverage from an employer workplace place in the interim, and the plan will sign this form testifying to that coverage.

Please let me know how things turn out. Your story could wind up helping many other people plagued by addiction to drugs they thought would make them healthy again.

This question previously appeared on the PBS NewsHour Making Sen$e website.