Medicare, the federal health insurance program primarily for individuals aged 65 and older, plays a crucial role in providing access to various healthcare services. However, when it comes to mental health services, there may be uncertainties among beneficiaries regarding coverage. In this article, we delve into the specifics to address the question: Does Medicare Cover Mental Health Services?
Does Medicare cover outpatient mental health services (such as therapy, counseling, or sessions with psychologists)?”
Medicare Part B, also known as Medical Insurance, provides assistance with mental health services typically received outside of a hospital setting, including clinics, doctor’s offices, or therapist’s offices, as well as services offered in a hospital’s outpatient department. Here are some of the outpatient services covered by Part B if your healthcare provider accepts assignment:
- A one-time ‘Welcome to Medicare‘ preventive visit within the initial 12 months of Part B enrollment, involving an evaluation of potential depression risk.
- Annual depression screening.
- Family counseling (if primarily aimed at aiding your treatment).
- Psychiatric assessment.
- Management of medications.
- Diagnostic tests.
- An annual ‘Wellness’ visit, providing an opportunity to discuss any changes in your mental health with your healthcare provider.
Additionally, Part B might cover a partial hospitalization program if specific criteria are met and your doctor confirms that inpatient treatment would otherwise be necessary.
It’s important to note that if you’re enrolled in a Medicare Advantage (Part C) plan, it may offer additional benefits like mental health counseling that aren’t included in Original Medicare. Be sure to review your plan for specific details.
Coverage for Mental Health Providers Outside the Hospital Setting
Medicare Part B extends coverage for mental health services when provided by the following healthcare professionals who accept assignment:
- Psychiatrists
- Clinical psychologists
- Clinical social workers
- Clinical nurse specialists
- Nurse practitioners
- Physician assistants
Costs for Outpatient Services
Generally, you’re responsible for 20% of the Medicare-approved amount for visits aimed at diagnosing or treating your condition, once you’ve met the Part B deductible. However, you pay nothing for an annual depression screening or alcohol misuse screening and counseling if your healthcare provider accepts assignment.
Inpatient Mental Health Coverage
Medicare Part A, also known as Hospital Insurance, aids in covering mental health services necessitating inpatient admission. These services can be availed in either a general hospital or a psychiatric hospital specializing in mental health conditions. Regardless of the hospital type, Part A covers:
- Semi-private room
- Meals
- General nursing care
- Medications
- Other hospital services and supplies required for your inpatient treatment
Costs for Inpatient Mental Health Services
Medicare assesses your utilization of hospital services, including those in psychiatric hospitals, in benefit periods. Each benefit period commences upon your inpatient admission and concludes after a continuous 60-day period without any inpatient care. Here are the Part A costs for hospital stays in 2024:
- Deductible: $1,632 for each benefit period
- Hospital coinsurance: $0 for the first 60 days of inpatient care per benefit period; $408 per day for days 61–90; $816 per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime)
- Skilled nursing facility (SNF) coinsurance: $0 for the first 20 days of inpatient care per benefit period; $204 per day for days 21–100; all costs for each day after day 100
There’s no cap on the number of benefit periods for mental health care in a general hospital. However, if you receive care in a psychiatric hospital, Part A only covers up to 190 days of inpatient psychiatric hospital services during your lifetime.
Prescription Drug Coverage for Mental Health
Neither Parts A nor B provide coverage for most prescription drugs. To obtain coverage for prescription drugs, you must enroll in a Part D prescription drug plan. These plans, managed by private insurance companies following Medicare’s regulations, vary in cost and the drugs they cover. While they aren’t obligated to cover all drugs, they must cover all (with some exceptions) antidepressant, anticonvulsant, and antipsychotic medications
Mental Health Services Not Covered by Medicare
Certain outpatient and inpatient mental health services are not included in Medicare coverage, such as:
- Transportation to or from mental health care facilities
- Provision of a private room (unless deemed medically necessary)
- Private duty nursing
- Amenities like a phone or television in your room
- Personal items such as toothpaste, socks, or razors
Need help? Call Health Plans in Oregon: 503-928-6918. Our assistance is at no cost to you.
