Mental health is just as important as physical health. Yet, for many Americans over 65, declining mental health stands in the way of truly enjoying their later years. Recent statistics show that 1 in 5 older adults (65+) battle symptoms of anxiety, depression, or both.
The good news is that Medicare helps pay for various mental health services. Here’s a look at what’s covered.
Does Medicare cover outpatient mental health services?
Yes, Medicare Part B covers mental health care you receive as an outpatient, meaning when you’re not admitted to a hospital as an inpatient. Some examples of outpatient settings where Part B would cover mental health services are doctors’ or mental health therapists’ offices, hospital outpatient clinics, and community mental health centers.
Mental health services covered under Medicare Part B include:
- One yearly depression screening when provided in a primary care doctor’s office
- Individual and group psychotherapy sessions with licensed psychiatrists, psychologists, clinical social workers, nurse practitioners, and other eligible professionals
- Medication management and injections you receive at a health care provider’s office
- Partial hospitalization programs (PHPs) — a type of mental health treatment you receive in the hospital, but you don’t stay overnight. PHPs are for individuals who need 20 hours per week of intensive mental health therapy.
- Intensive outpatient programs (IOPs) services as of January 2024. IOP is a structured mental health therapy for a minimum of nine hours per week.
- Diagnostic tests and other services to evaluate and support an outpatient mental health treatment plan
In addition to mental health care, Medicare Part B helps pay for outpatient treatment services for substance use disorders related to drugs or alcohol. These include:
- Medication, counseling, therapy, and testing to treat opioid use disorder
- One free yearly screening to determine if you are misusing alcohol
- Four counseling visits per year for people who are misusing alcohol but who do not fit the definition of “abuse”
- Treatment sessions for people with alcohol abuse for as long as they’re considered medically necessary
Paying for outpatient mental health services with Medicare
For Medicare to cover outpatient mental health services, the provider must accept Medicare assignment. This means they agree to receive Medicare’s approved payment amount.
Medicare provides coverage for one free yearly depression screening when performed by a primary care provider who accepts Medicare assignment. Annual wellness visits and alcohol misuse screenings are also fully covered.,
For these services to be covered to the extent that Medicare pays, you must first meet the annual Medicare Part B deductible for all other covered outpatient mental health services subject to Part B cost sharing. Then, you pay 20% of the Medicare-approved amount as coinsurance for each visit or service. Additional copayments or coinsurance may also apply if care is provided in a hospital outpatient setting.
To reduce your out-of-pocket costs for outpatient mental health services, consider a Medigap (Medicare supplemental insurance) plan or see if you qualify for a Medicare Savings Program.
Does Medicare cover inpatient mental health services?
Yes, Medicare Part A covers inpatient mental health services when you’re admitted to either a general hospital or psychiatric hospital. Coverage includes inpatient care and any services provided by health care professionals during the hospital stay.
While you can receive mental health services in a general or psychiatric hospital under Medicare, there are differences in coverage based on the facility.
In a general hospital, you have access to unlimited benefit periods for mental health services. A benefit period refers to how Medicare measures your use of hospital and skilled nursing facility services. Each benefit period begins when you enter a hospital or skilled nursing facility. It ends when you haven’t received care as an inpatient for 60 days in a row. There are no lifetime limits on the number of benefit periods covered in a general hospital.
For psychiatric hospitals, Medicare still covers multiple benefit periods but only pays for up to 190 days total over your lifetime. After reaching this 190-day limit, you must pay out-of-pocket for any additional mental healthcare in a psychiatric hospital.
What do Medicare beneficiaries pay for inpatient mental health services?
When admitted for inpatient mental health treatment, you pay the following per benefit period:
- The Part A deductible when you’re first admitted
- After paying the deductible, Medicare covers 100% of approved services for the first 60 days of your benefit period
- If your hospital stay exceeds 60 days, daily copayment amounts for each day apply for hospital days 61 through 90
- If you need to stay in the hospital longer than 90 days, Medicare’s 60 lifetime reserve days start covering days 91 and beyond. You pay a daily copayment for each lifetime reserve day used
- Once all 60 lifetime reserve days have been used, you pay 100% of the costs for any hospitalization that lasts more than 90 days
Additionally, for any services provided by doctors or other clinicians during an inpatient stay, you pay 20% of the Medicare-approved amount, as these are covered under Medicare Part B.
To help minimize out-of-pocket costs for mental healthcare not covered by Medicare Part A, consider Medicaid if you qualify, Medigap plans, or hospital charity care programs. Unlike Original Medicare, most Medicare Advantage (MA) plans have an annual limit on out-of-pocket spending for covered medical services, including inpatient mental health care. But it’s important to understand the out-of-pocket costs for any MA plan you’re considering, as they do vary by plan. MA plans also tend to have prior authorization requirements.
Does Medicare cover mental health prescription medications?
Yes, you can get mental health prescription medication coverage through a stand-alone Medicare Part D plan or an MA plan that includes prescription coverage.
Medications injected or infused in the doctor’s office or clinic are covered under Medicare Part B, not Part D.
It’s a good idea to review your medications and potential out-of-pocket costs each year during open enrollment. Medicare Part D and MA prescription medication benefits can vary year-to-year and across plans.
Paying for mental health prescription medications
The specific medications covered and your out-of-pocket expenses depend on your insurance plan’s covered medication list – or formulary – and pricing tiers.
To get help paying for mental health prescription medications, look into:
- Medicare Low-Income Subsidy (Extra Help) to assist with costs Read our overview of Extra Help to learn whether you’re eligible.
- Pharmaceutical company patient assistance programs offering free or low-cost brand-name medications
- State Pharmaceutical Assistance Programs that pay some Part D expenses based on income
Comparing mental health benefits: Original Medicare vs Medicare Advantage
Medicare Advantage plans cover mental health services similar to Original Medicare but with some key differences:
- Outpatient: Your copays, coinsurance amounts, and yearly out-of-pocket maximums can vary across MA plans. For example, Medicare Advantage plans often charge set copays for services, while Original Medicare has a 20% coinsurance. Most MA plans have an annual out-of-pocket maximum that limits your out-of-pocket expenses, but Original Medicare does not have an annual cap on costs. Covered providers also differ between MA plans. Check whether your current mental health professionals are in-network.
- Inpatient: Generally, MA plans offer the same level of inpatient mental health coverage as Original Medicare. Some MA plans may provide extra benefits. Contact your MA plan issuer for coverage details.
- Medications: Each plan’s drug list and costs for mental health medications differ, just like standalone Part D plans do.
Nearly all (98%) MA plans required prior authorization for certain mental health and substance use disorder services in 2022. Carefully check the specifics of each plan’s mental health benefits before you enroll. Ensure your medications, therapists, doctors, and care costs will be covered.
What mental health services are not covered under Medicare?
While Medicare covers many mental health services, benefits for the following are not included:
- Transportation for mental health care visits
- Meals or food costs
- Social support groups (as opposed to clinically-led group psychotherapy, which is covered)
- Job skills testing or training if not part of a mental health treatment regimen
- Private duty nursing
- Phone or television service charges
- Personal items like razors or toothpaste
- A private hospital room (unless deemed medically necessary)
What’s new: Changes to Medicare’s mental health benefits
- Telehealth: CMS temporarily let Medicare beneficiaries use telephone or video visits for mental health services during the COVID-19 pandemic. However, these telehealth flexibilities have now been made permanent under Medicare. That means if telehealth works better for you, you can continue your mental health care via telephone or video from anywhere.
- Intensive outpatient program (IOP): In November 2023, CMS added coverage of intensive outpatient programs for mental health treatment for Medicare beneficiaries effective January 1st, 2024. These services must be provided by hospitals, community mental health centers, federally qualified health centers, or rural health clinics. To qualify for Medicare IOP coverage, a physician must confirm the need for this level of care every other month.
- Covered providers: As of Jan. 1, 2024, Medicare coverage will include mental health services provided by marriage and family therapists as well as mental health counselors who accept Medicare assignment.
Maggie Aime is a health, wellness and medical personal finance writer. With over 25 years in healthcare and a passion for education, she draws on her rich experience across nursing specialties, case management, revenue management, medical coding, and utilization review nurse consultant roles to create content that informs, inspires, and empowers. She’s passionate about educating people about all aspects of disease prevention, health and wellness, and how to navigate the US healthcare system. She’s the owner of The Write RN, LLC.
Footnotes
Tags: mental health
