Medicare should cover alcoholism and substance use disorder treatment for a parent if:

• Their provider states that their services are medically necessary
• They receive services from a Medicare-approved provider or facility
• And, their provider sets up their plan of care

Medicare covers treatment in both inpatient and outpatient settings. Here are just a few examples of the services that Medicare covers:

• Psychotherapy
• Opioid treatment program (OTP) services
• Patient education regarding diagnosis and treatment
• Post-hospitalization follow-up

Part A should cover their care if they are hospitalized and needs substance use disorder treatment. If they are in an inpatient psychiatric hospital, keep in mind that Medicare only covers a total of 190 lifetime days. Once their limit has been reached, though, Medicare may cover care at a general hospital. A plan’s cost-sharing rules for an inpatient hospital stay should apply.

Part B should cover outpatient substance use disorder care they receive from a clinic, hospital outpatient department, or opioid treatment program. Original Medicare covers these services at 80% of the Medicare-approved amount. As long as they receive the service from a participating provider, they will pay a 20% coinsurance after meeting their Part B deductible. Visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to find participating providers. If they are enrolled in a Medicare Advantage Plan, contact their plan for information about costs, coverage, and in-network providers for substance use disorder treatment.

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Published by: AARP

The Inflation Reduction Act of 2022 will help millions of Americans better afford their life-sustaining medications and also help them pay for other out-of-pocket health care costs. Here are the answers to some commonly asked questions about the new law. Go to AARP.org/fiercedefender to learn more about the law’s health care provisions and AARP’s role in fighting for these changes.

Lowering Drug Prices 

When will Medicare drug-price negotiations begin?

The U.S. Department of Health and Human Services (HHS) will begin the negotiation process in 2023. By 2024 the agency will identify which 10 prescription drugs will be the first whose prices will be negotiated. By 2029, up to 60 drugs will be subject to price negotiation.

When can we expect to see a difference in drug prices?

The first prices resulting from the negotiations between HHS and drugmakers will take effect in 2026.

Which drugs will be subject to negotiation?

The drugs selected will be among the 100 medications that Medicare spends the most on. The drugs selected for negotiation can’t have any direct competition from generic or biosimilar (a generic form of a biologic drug) alternatives. And they have to have been on the market for a certain number of years.

What will happen to the money Medicare saves from lower prices?

Lower prices mean the Medicare program will save money while providing the same drugs to beneficiaries. And beneficiaries taking drugs with negotiated prices will have lower out-of-pocket costs. The money Medicare doesn’t need to spend on medicines should help bolster the program’s budget, reduce premiums and improve long-term solvency.

Is there anything else in the new law to help rein in soaring drug prices?

Yes. Starting in 2023 drugmakers who raise their prices more than the rate of general inflation will have to pay Medicare a rebate for the amount of their price increases above the rate of inflation.  

Medicare Part D Changes

When will the $2,000 out-of-pocket cap take effect?

Beginning in 2025 Medicare beneficiaries will not have to spend more than $2,000 a year on their medications. Before that, in 2024, Medicare enrollees who reach the catastrophic phase of the Part D prescription drug program will not have to pay any more out-of-pocket for their drugs during that year.  

Which vaccines will be free?

Starting in 2023 Medicare will cover at no cost to beneficiaries vaccines that have been approved for adults by the Centers for Disease Control and Prevention (CDC) Advisory Committee for Immunization Practices. Among the shots to be fully covered is the shingles vaccine, which currently requires cost-sharing for those on Part D.

When will my insulin be capped at $35 a month?

Beginning in 2023, copays for a 30-day supply of any insulin that a Medicare drug plan covers will be capped at $35. 

What will happen to my Part D premium?

Beginning in 2024 and continuing through 2029, Part D premiums cannot increase by more than 6 percent a year. Be aware that premiums for these private insurance drug plans vary widely depending on which plan you pick and where you live.

Do these changes apply to Medicare Advantage plans?

Yes. Almost all Medicare Advantage (MA) plans include prescription drug coverage, and those who belong to the few that do not can enroll in a standalone Part D prescription drug plan. All the Part D changes apply to all Medicare beneficiaries with drug coverage — whether they enroll in original Medicare with a standalone drug plan or an MA plan with prescription drug coverage.

Making Health Care More Affordable

How will the new law help Medicare beneficiaries pay Part D premiums and copays?

The new law expands eligibility for Medicare’s Part D Low-Income Subsidy (LIS) benefit, also known as the Part D Extra Help program. Beginning in 2024, Medicare beneficiaries with annual incomes of up to 150 percent of the federal poverty limit ($20,385 for an individual in 2022) who also meet the program’s resources limit can qualify for full benefits under the Extra Help program. The income threshold for full benefits currently is 135 percent of the federal poverty guidelines ($18,347 for an individual in 2022).

I’m not on Medicare yet. Is there anything in the law to help me afford ACA policies?

Yes. The new law extends until the end of 2025 the expanded Affordable Care Act (ACA) premium subsidies that were instituted under the American Rescue Plan Act of 2021. This means that more people will continue to be eligible for the ACA subsidy and no one will have to pay more than 8.5 percent of their annual income for an ACA health insurance plan premium.

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If you are dissatisfied with your Medicare Advantage or Part D prescription drug plan for any reason, you can choose to file a grievance. A grievance is a formal complaint that you file with your plan. It is not an appeal, which is a request for your plan to cover a service or item it has denied. Times, when you may wish to file a grievance, include:

• If your plan has poor customer service
• You face administrative problems (such as the plan taking too long to file your appeal or failing to deliver a promised refund)
• You believe the plan’s network of providers is inadequate

To file a grievance:

• Send a letter to your plan’s Grievance and Appeals department. Check your plan’s website or contact them by phone for the address.
• You can also file a grievance with your plan over the phone, but it is best to send your complaints in writing.
• Be sure to send your grievance to your plan within 60 days of the event that led to the grievance.
• You may also want to send a copy of the grievance to your regional Medicare office and to your representatives in Congress if you feel they should know about the problem. Go to www.medicare.gov or call 1-800-MEDICARE to find out the address of your regional Medicare office.
• Keep a copy of any correspondence for your records.
• Your plan must investigate your grievance and get back to you within 30 days. If your request is urgent, your plan must get back to you within 24 hours. If you have not heard back from your plan within this time, you can check the status of your grievance by calling your plan or 1-800-MEDICARE.

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A new analysis from the AARP Public Policy Institute finds drug companies have increased prices for many brand name Part D drugs in 2022, contributing to affordability challenges for people with Medicare.

According to the report, 75 of the 100 brand name drugs with the highest Medicare Part D spending in 2020 saw their list prices increase in January 2022; none experienced a decrease. The average increase was 5%, with some drug prices (12 of 75) growing by nearly 8%. In 2020, these 75 drugs were used by more than 19 million Part D enrollees and accounted for nearly half of all Medicare Part D prescription drug spending ($93.2 billion out of $198.7 billion).

These price hikes will have a cumulative impact, as they are building on those in prior years. For example, the typical cost of a brand-name medication in 2020 was $6,600–$3,700 more than it would have been, had drug prices not grown faster than inflation every year since 2006. For Medicare beneficiaries, who take an average of four to five prescription drugs per month and have a median annual income of just under $30,000, this can be a significant burden.

Prescription drug price hikes also affect Medicare’s financing. The Medicare Payment Advisory Commission (MedPAC) has consistently cited high prices as a key reason for the growth in Medicare Part D spending. From 2013 to 2018 alone, Part D spending on prescription drugs increased by 26%. The commissioners attributed “nearly all of the growth . . . to higher prices rather than an increase in the number of prescriptions filled by beneficiaries.”

And the consequences don’t stop there. As AARP notes, “High and growing prescription drug prices will eventually affect all Americans in some way . . . those with private health insurance will pay higher cost-sharing and premiums. Increased government spending driven by drug price increases will lead to higher taxes and/or less spending for other priorities. Equally important, high drug prices and related costs will prompt more older Americans to stop taking necessary medications.”

Immediate action is needed to reform the nation’s drug pricing system in ways that will strengthen Medicare and improve beneficiary well-being. Absent such interventions, prices, and unaffordability will continue to rise, as will risks to the program. An ever-growing number of Americans could be priced out of needed medications and coverage, leading to worse health outcomes and higher costs in the future. At the same time, policymakers could seek to control government spending through Medicare changes that threaten beneficiary health and financial security.

Medicare Rights supports comprehensive efforts to lower prescription drug prices, including as outlined in the House-passed budget reconciliation bill. Though its changes are less comprehensive than originally envisioned in H.R. 3, it retains that bill’s core elements by capping beneficiary out-of-pocket (OOP) drug costs; realigning Part D financial obligations; penalizing drug manufacturers for price hikes that outpace inflation; and allowing Medicare to negotiate drug prices. Together, these policies would achieve historic coverage and affordability gains, better ensuring that all people with Medicare have meaningful access to care.

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