Does Medicare cover mental health?

Does Medicare cover mental health services? | Medicare mental health providers | Costs | Other ways to save

One in five Medicare beneficiaries lives with a mental health disorder, according to the National Library of Medicine. That’s why it’s crucial that older adults understand what mental health services they have coverage for. 

In this article, we’ll discuss Medicare’s mental health coverage, how to find a mental health provider near you, what you can expect your out-of-pocket costs to be for mental health services, and how to save on mental health medications. 

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Does Medicare cover mental health services?

Medicare does cover mental health services and treatments. Each beneficiary is eligible for Medicare psychiatric coverage, psychotherapy, and treatment for other mental health conditions. 

If you’re admitted to a psychiatric hospital as an inpatient, your coverage will fall under Medicare Part A. Part A covers a percentage of the cost of the room, nursing, meals, etc. 

If you’re going to your primary care physician in an outpatient setting for mental health treatment, your Medicare coverage will fall under Medicare Part B. Part B covers healthcare provider visits to see a psychiatrist, clinical psychologist, clinical social workers, clinical nurse specialists, nurse practitioners, and physician assistants. Part B also covers outpatient mental health services for the treatment of substance abuse.

In addition, Medicare Part B will cover outpatient mental health services, including services that are usually provided outside a hospital, in three types of settings:

1. A healthcare provider’s office
2. A hospital outpatient department
3. A community mental health center

There is a lifetime limit of 190 days of care you receive in a freestanding inpatient psychiatric hospital. Once you’ve exhausted your lifetime reserve days, you cannot get them back. However, you can apply for a Medigap policy that may provide up to an additional 365 lifetime reserve days. Additionally, you may be able to receive coverage for mental health services at a general hospital or other setting.

What’s covered

• One depression screening per year. The screening must be done in a primary care healthcare provider’s office or primary care clinic that can provide follow-up treatment and referrals.
• Individual and group psychotherapy with healthcare providers (or with certain other licensed professionals, as the state where you get the services allows).
• Family therapy, if the main purpose is to help with your treatment.
• Testing to find out if you’re getting the services you need and if your current treatment is helping you.
• Psychiatric evaluation.
• Medication management.
• Certain prescription drugs that aren’t usually “self-administered” (drugs you would normally take on your own), like some injections.
• Diagnostic tests.
• Partial hospitalization program.
• A one-time “Welcome to Medicare” preventive visit. This visit includes a review of your possible risk factors for depression.
• A yearly “Wellness Visit”. Talk to a primary care doctor or other healthcare provider about changes in your mental health since your last doctor visit.

If you have a Medicare Advantage plan, it may offer extra benefits not covered by Original Medicare. 

Does Medicare cover therapy?

Yes. Medicare Part B will cover individual therapy, group therapy, and family counseling if the goal of therapy is to treat your mental health condition. 

What’s not covered

• Transportation to or from mental health care services.
• Support groups that bring people together to talk and socialize. Note: This is. different from group psychotherapy, which is covered.
• Testing or training for job skills that aren’t part of your mental health treatment.

If your coverage for mental health services and/or treatment has been denied by Medicare, you have the right to file for an appeal. You will need a copy of any documentation your healthcare provider can provide you to benefit your case. You can visit medicare.gov to file your appeal.

Medicare mental health providers near you

The Centers for Medicare and Medicaid Services (CMS) has a great tool called the Care Compare that gives you a Medicare mental health providers list that accepts Medicare. The Care Compare tool allows you to search for hospitals and providers near you that accept Medicare. Enter your zip code, the provider type, and any additional keywords to help find the right health professional for you.

How much do mental health treatments cost with Medicare?

Medicare does not cover 100% of the costs of mental health treatments. There are many factors that can impact your out-of-pocket costs. These factors include other Medicare supplemental insurance (Medigap) or other insurance plans you may have, how much your healthcare provider charges if your healthcare provider accepts Medicare assignment and the type of facility you get care from. Generally speaking, Original Medicare covers outpatient mental health services at 80% of the Medicare-approved amount once you meet your deductible.

Part A

Inpatient mental health care will be covered by Medicare Part A. It’s important to know that the deductible under Part A is per benefit period, not per calendar year. A benefit period begins the day that you are admitted for inpatient care and ends 60 days after your last inpatient service. This means you could pay the deductible more than once per calendar year.

For each benefit period, you can expect to pay the following. Check your plan to find specific amount for the current year: 

• A set deductible.
• Days 1–60: $0 coinsurance per day.
• Days 61–90: a specific amount of coinsurance per day.
• Days 91 and beyond: A certain amount of coinsurance per each “lifetime reserve day” after day 90 (up to a maximum of 60 reserve days over your lifetime unless you have a Medigap policy that provides more).
• Each day after the lifetime reserve days: All costs.

Costs may be minimized with Medicaid or charity care assistance if the expense is unaffordable. A Medigap or other supplemental insurance policy also may cover some or all of these costs.

How does a Medicare beneficiary receive mental health services if they exhausted their lifetime reserve days?

There are a few options to receive mental health coverage after you’ve exhausted your lifetime reserve days. 

First, the hospital benefit periods reset when you’ve been out of the hospital for 60 consecutive days. Then, you can get more hospital time covered if necessary.

You could also receive mental health coverage through Medicaid if you’re eligible, private healthcare coverage, or a county-specific program. Or adding a Medigap policy may provide you with 365 additional lifetime reserve days. 

“When referring to inpatient mental health and/or substance use treatment, or outpatient mental health and/or substance use treatment, there are a few payment options,” says Aimee Johnson, LCSW, a licensed clinical social worker with expertise in mental health and substance abuse. “Some counties or local jurisdictions have programs and services to provide coverage and treatment programs through partner organizations. Contact your local community mental health and substance use walk-in clinic to inquire or [call] the county crisis line in your area.”

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Part B

If your healthcare provider accepts Medicare assignment, you’ll pay nothing out of pocket for your annual depression screening or wellness visit. After you’ve met the annual Part B deductible, you’ll be responsible for 20% of the Medicare-approved amount for outpatient mental health care.

Drug coverage under Medicare

Medicare Part D is the part of Medicare that includes prescription drug coverage for the treatment of depression and anxiety, and many other mental health conditions. You can also receive prescription drug benefits with a Medicare Advantage plan (Part C) that includes prescription coverage. Since each Part C and D plan varies in coverage and drug formularies, it’s difficult to get an estimate on how much your medications would cost.

You can use the CMS plan comparison tool to input your zip code and then search for your medications to see what your out-of-pocket costs will be across various plans. The tool breaks down all the costs, including monthly premiums, coinsurance for your medications, and how long it will take you to reach your annual deductible.

The plan comparison tool even compares the price differences of all your medications between the local pharmacies you select and pharmacy delivery options in your area.

Other ways to save on mental health medications

1. Medicare Extra Help

If you’re considered low-income or dual-eligible for both Medicare and Medicaid, then it’s possible that anxiety and depression medications could be covered with help from the Extra Help program under Medicare Part D. 

This federal program reduces out-of-pocket costs by eliminating prescription premiums as well as deductibles and reducing copays depending on what level you qualify for. To qualify for Extra Help, you must be enrolled in Medicare and have a limited income and resources.

2. SingleCare coupons

Medicare plans and other health insurance policies may not cover the full cost of mental health medications, especially if you haven’t met your deductible. But there is a way for you to get those necessary prescriptions at reduced rates. SingleCare offers discount coupons that can save patients as much as 80% on their medications—even if they have Medicare or another type of healthcare coverage plan. Sometimes, you can save more money by using SingleCare instead of your Medicare prescription drug plan. However, you can’t use both SingleCare and Medicare on the same prescription.

Prescription drug prices often change. These are the most accurate medication prices at the time of publishing. Click the link under “Savings options” to see updated drug prices.

RELATED: How young is too young for antidepressants? How old is too old?

3. Other savings programs

Drug manufacturers, especially of brand-name drugs, sometimes offer manufacturer coupons. These coupons typically cannot be used with Medicare but rather instead of Medicare. Some manufacturers and non-profit organizations also offer patient assistance programs for additional financial assistance. However, there are often strict eligibility requirements for manufacturer rebates and patient assistance programs. Contact the manufacturer of your medication for more information.

4. Free samples at your doctor’s office

When you begin a new medication, your healthcare provider may be able to provide you with a free sample. However, this isn’t a long-term savings solution.