Are Mental Health Services Covered By Medicare?
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Medicare, a cornerstone of health insurance for seniors and select others in the U.S., offers a multifaceted approach to mental health coverage. Through its various parts, from inpatient services in Part A to prescription drug coverage in Part D, Medicare aims to address the mental well-being of its beneficiaries.
Learn what you can expect to pay for mental health services and options if you don’t have Medicare to cover your costs.
When Does Medicare Cover Mental Health Services?
Medicare has several provisions for mental health services, including Original Medicare or Medicare Advantage.
Inpatient Mental Health Services (Part A)
Medicare Part A covers inpatient mental health services, whether you're admitted to a general or psychiatric hospital. Coverage includes semi-private rooms, meals, general nursing, drugs (including methadone for opioid disorders) and other inpatient-related services and supplies.
What You Pay Out of Pocket
The following is what you will pay for inpatient care under Part A:
Deductible for each benefit period
$0 coinsurance per day of each benefit period
$400 coinsurance per day of each benefit period
Days 91 and beyond
$800 coinsurance per each lifetime reserve day after
day 90 for each benefit period (up to 60 days over your lifetime)
Beyond lifetime reserve days
Medicare-approved amount for mental health services
Outpatient Mental Health Services (Part B)
Medicare Part B provides coverage for mental health services outside of hospitals, such as clinics and professionals like therapists, psychiatrists, clinical psychologists, clinical social workers and nurse practitioners. Other outpatient services that may be covered include annual depression screenings, individual and group psychotherapy, psychiatric evaluations, certain prescription medications and diagnostic tests and yearly wellness visits are covered as well.
Additionally, Medicare covers treatment services for opioid use disorders in specific programs. This includes medications like methadone and applicable in-person or virtual mental health counseling. Medicare will also provide an annual alcohol misuse screening and, if required, up to four counseling sessions for those identified as misusing alcohol.
Finally, Part B can cover partial hospitalization services provided by community mental health centers or hospitals in certain conditions. Medicare may also cover occupational therapy related to mental health treatment and education about the patient's condition.
What You Pay Out of Pocket
The following is what you will pay for outpatient care under Medicare Part B:
$226 every year.
Outpatient mental health care
Partial hospitalization mental health care
After you meet the Part B deductible:
If obtained from a Medicare-enrolled provider, opioid use disorder treatment services come with no additional charges after the Part B deductible. If these services, including partial hospitalization and other outpatient services, are rendered in a hospital outpatient department, there might be an extra copayment or coinsurance fee.
Does Medicare Advantage (Part C) Cover Mental Health Services?
Medicare Advantage plans are Medicare-approved health insurance plans that are sold by private companies and include coverage for all the mental health services listed above.
Does Medicare Cover Prescription Drugs for Mental Health?
Medicare Part D provides drug coverage through approved plans run by private insurance companies. While each plan's costs and covered drugs may vary, nearly all plans include antidepressants, anticonvulsants and antipsychotic medications. Before enrolling, verify if your mental health prescription drugs are covered.
Drug plans can update their formulary lists during the year in response to new medical data, drug releases or therapeutic changes. Sometimes, plans might replace a brand-name drug with a new generic version. If a drug you're taking is affected by these changes, your plan must provide either a 30-day notice before the change or a one-month drug supply with prior plan rules when you request a refill.
What Types of Mental Health Services Aren’t Covered by Medicare?
Medicare does have some exclusions depending on what part of Medicare you look at.
Medicare Part A doesn't cover certain mental health-related amenities and services such as private duty nursing, in-room phones or televisions, personal care items like toothpaste and razors and private rooms unless they are medically essential.
Medicare Part B excludes some mental health-related services, such as meals and transportation to care facilities. It also doesn't cover social-oriented support groups as opposed to therapeutic group sessions. Additionally, any job skill assessments or training not directly tied to mental health treatment are not covered.
While Medicare drug prescription plans may cover a wide range of drugs, there may be a specific type of medication that is not eligible for coverage. If your drug plan doesn’t cover a necessary medication, you have the right to seek a coverage determination, which is a request for an exception. You, your doctor or another representative can submit a verbal or written request for an exception that includes supporting reasons for the medication request to your plan sponsor.
How To Get Medicare for Mental Health Services
People qualify for Medicare and its mental health benefits at age 65 or earlier if they've received Social Security Disability Insurance (SSDI) or certain Railroad Retirement Board (RRB) disability benefits for 24+ months. Those with amyotrophic lateral sclerosis (ALS) qualify immediately, and some with end-stage renal disease (ESRD) may also be eligible.
If you meet the above criteria and receive Social Security due to disability or retirement, you are auto-enrolled in Medicare Part A and B. You can decline Part B but can't decline Part A without retracting your Social Security application and repaying all benefits.
For those eligible for Medicare, but who are not automatically enrolled, you can join during open enrollment, which usually runs from November 1 to December 15 for coverage beginning January 1. Meanwhile, you can switch from Original Medicare to an MA plan January 1 to March 31.
How To Get Mental Health Assistance Without Medicare
Obtaining mental health assistance without Medicare can be challenging but not impossible. Here are several potential avenues for finding such care:
- Sliding scale clinics: Some therapists and mental health clinics offer services based on your income, allowing for more affordable care if you can't pay the standard rates.
- Community health centers: Many communities have local health centers that provide mental health services on a sliding fee scale.
- University clinics: If you're near a university or college that has a psychology or psychiatry department, they might have a training clinic where students, supervised by licensed professionals, provide therapy at reduced rates.
- Employee assistance programs (EAP): If you are employed, check to see if your employer offers an EAP. These programs often provide free short-term counseling services.
- Local nonprofits and charities: Some organizations provide free or reduced-fee counseling services. For example, organizations serving specific groups, such as veterans, might have associated mental health resources.
- Online counseling services: Platforms like BetterHelp, Talkspace and 7 Cups offer online counseling for a fee, which might be less than traditional in-person sessions. Some also provide financial assistance or sliding scale fees.
- Helplines: While not a replacement for therapy, there are numerous helplines for immediate support, such as the Suicide and Crisis Lifeline.