For the staff at the Senior Recovery Center in Maplewood, Minn., helping older adults overcome substance use disorders is a calling, said Christine Martinek, a licensed alcohol and drug counselor there. 

But it’s a more challenging calling when the adults who need treatment are on Medicare.

“Every day, I get phone calls saying, ‘My dad is 70 years old and he needs help.’ But he’s got Medicare, and you don’t know how many times I have to tell people that we can’t help them,” Martinek said.

For the 52 million Americans age 65 and older, Medicare is a lifesaver, providing health insurance regardless of income, medical history or health status. But for the growing number of older adults who need treatment for an alcohol or drug use disorder, the federal program falls woefully short, according to experts, advocates and medical groups.

At least 2 percent of Medicare beneficiaries 65 or older — about 1 million people — had a past-year alcohol or drug use disorder between 2015 and 2019, according to a study published in the American Journal of Preventive Medicine in August. But only 6 percent received treatment. Of those who didn’t receive treatment, 38 percent cited financial barriers.

That may be because entire categories of care recommended by the American Society of Addiction Medicine aren’t covered by Medicare, putting it out of step with coverage typically offered by private insurance and Medicaid.

For example, Medicare doesn’t recognize independent substance use treatment facilities like the Senior Recovery Center, which offers six months of outpatient addiction care for $5,500 out of pocket, as a provider type eligible for payment.

While low-income people might qualify for Medicaid or other state programs and wealthier individuals can pay out of pocket, those covered by Medicare often find the center financially out of reach. 

“If they can’t pay out of pocket, or they’re not low-income, then they’re in real trouble,” Martinek said. 

Coverage gaps

Medicare allows authorized physicians at substance use treatment facilities to bill for treatment. But not every program employs a doctor or has a partnership with one.

Medicare generally doesn’t pay for the licensed alcohol and drug counselors, peer support specialists or marriage and family therapists who make up a large portion of the behavioral health workforce unless they are working with a doctor.

It doesn’t cover intensive outpatient treatment, a type of care typically offered for people who need at least nine hours a week of treatment. 

And it doesn’t pay for residential inpatient rehab for drug and alcohol treatment — and there’s a 190-day lifetime limit for inpatient care at psychiatric hospitals. 

The large swath of exceptions means only about 42 percent of the 16,000 substance use treatment facilities in the U.S. accept Medicare, while more than 70 percent accept Medicaid, according to the Substance Abuse and Mental Health Services Administration.

“It’s damn hard to find good treatment for Medicare recipients,” said Shawn Ryan, chair of the American Society of Addiction Medicine, or ASAM, and chief science officer of BrightView Health, one of the largest addiction treatment services in the Midwest. 

Part of the issue is Medicare is exempt from laws requiring parity between behavioral health and physical health benefits. 

That means people who had comprehensive coverage of substance use disorder while privately insured could lose coverage of those providers and services when they age into Medicare.

“People would often find out they didn’t have coverage of something after getting a denial when trying to get treatment,” said Deborah Steinberg, who co-authored the study in the American Journal of Preventive Medicine and is a health policy attorney for the Legal Action Center, which advocates improved addiction coverage in Medicare. 

According to the Centers for Disease Control and Prevention, while drug overdose death rates for older adults are typically lower than for other age groups, they have been increasing over the past two decades. Drug overdoses among people 65 and older more than tripled over the past two decades, to 8.8 deaths per 100,000 people, particularly impacting Black men.

Alcohol-induced deaths in the 65 and older population have also been increasing since 2011 and rose more than 18 percent from 2019 to 2020, according to the CDC. 

The rate of alcohol-induced deaths among all age groups was second-highest for males between the ages of 65 and 74 and highest for men between 55 and 64. 

Even when Medicare covers the treatment, it can be difficult for patients to find providers offering it, especially in rural areas. Some providers have decided not to accept Medicare, citing low reimbursement rates or the misconception that Medicare enrollees don’t need addiction care. 

The shortage of addiction professionals has compounded the issue. Substance use disorder care is typically siloed from the rest of the health care system, so while primary care doctors can prescribe treatment, they often don’t. 

“Very few of our colleagues even take Medicare,” said Ryan.

Legislative fixes

That could change under policies being considered by the Biden administration and Congress, though the moves aren’t expected to transform Medicare behavioral health benefits. 

The Senate Finance Committee is proposing Medicare coverage of marriage and family therapist services and licensed professional counselors as part of the bipartisan behavioral health package it has been working on this year. Advocates have asked lawmakers to clarify that the changes would include substance use disorder treatment.

While marriage and family therapists and licensed professional counselors like Martinek at the Senior Recovery Center make up about 40 percent of the behavioral health workforce, they currently can’t bill Medicare unless they are working with a physician.  

Changing that “would definitely help in Medicare to have more types of providers who are covered and can bring care to people,” said Julie Carter, senior federal policy associate at the Medicare Rights Center. 

During a markup in September, the House Ways and Means Committee approved similar legislation, as well as legislation that would create a new benefit category for intensive outpatient services for people who need at least nine hours of care per week, which can include counseling, medication management and other therapies. Advocates note that provision would apply only to providers that can currently bill Medicare like hospitals and licensed physicians, not the free-standing substance use disorder facilities where most intensive outpatient treatment is available.  

While the federal Centers for Medicare & Medicaid Services has expressed interest in finding a way to pay for intensive outpatient treatment, it did not make any changes in the latest physician payment rule. 

Groups like the American Medical Association and ASAM have also called on Congress to require parity in Medicare, which they say would address limitations on treatment in the program. In November, the AMA passed a resolution calling for Congress to mandate parity in Medicare coverage of mental health and substance use disorder benefits. 

Doing so could mean higher payment rates for behavioral health providers that say they are not paid in line with other specialties. 

Intensive outpatient treatment

About 45 percent of substance use disorder treatment facilities surveyed by SAMHSA offer intensive outpatient treatment, a model developed by addiction psychiatrist George Kolodner in the 1970s as an alternative to residential treatment.

Kolodner today describes it as “outpatient rehab” that costs 20 percent less than inpatient care but shows better results in terms of patients staying in care. For nine to 19 hours a week, patients go to counseling and support groups and receive withdrawal management.

Such treatment is typically covered by private insurance and most state Medicaid programs and recommended by ASAM. 

Kolodner, who founded Kolmac Outpatient Recovery, said because Medicare doesn’t cover intensive outpatient treatment, he has to turn some of those patients away.

He could usually work with patients who were in treatment before turning 65 because the most expensive parts of treatment, withdrawal management, occur during the early stages of the program. 

“God forbid someone was over 65 when they chose to start treatment. They couldn’t even come in the door unless they paid out of pocket, and the average person couldn’t afford this,” he said. 

Kolmac’s program costs about $8,000 for two months of treatment. 

Opioid treatment programs 

CMS has experience standing up new benefit programs. After Congress passed legislation in 2018, Medicare started covering opioid treatment programs: clinics that use methadone and other forms of medication to help patients reduce or quit the use of opioids.

Still, the vast majority of Medicare beneficiaries with substance use disorders have alcohol use disorder.

Of the Medicare beneficiaries with a substance use disorder, 87 percent had an alcohol use disorder and 8.6 percent had an opioid use disorder, according to the study in the American Journal of Preventive Medicine.

That makes it imperative for Medicare to keep evolving to cover the full range of substance use treatment, advocates say. 

“I think people around the country are waking up to how serious this is,” Steinberg said. 

“There is momentum to fix it.”

This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations and the The NIHCM Foundation.