According to the National Institute of Mental Health, one in five, or 57.8 million U.S. adults has mental health disease. For Americans 65 years of age and older, Medicare covers inpatient and outpatient mental health services. Ranging from mild to severe with the potential to impact your life, mental illness treatments, and their management varies according to your health needs. Let's delve into the topic of how Medicare covers mental health.
According to the NIMH, one in five American adults lives with a mental illness.
Medicare Parts A and B provide coverage for mental health benefits, but there are limitations.
There is a lifetime maximum of 190 days for inpatient psychiatric admissions under Medicare Part A.
Medicare Part B covers free yearly depression screenings if completed by a doctor who accepts Medicare assignments.
Medicare mental health coverage
In Original Medicare, mental health services are covered under Parts A and B. Part A covers inpatient services, while Part B covers outpatient services. In the past, Medicare reimbursed outpatient mental health services at a lower rate than other Part B benefits. But in 2008, the government enacted laws making access to mental health an essential service, and now outpatient mental health care is covered the same under Part B.
When you are admitted to a hospital or a psychiatric hospital, you are an “inpatient” because you are “in” the hospital. Part A covers inpatient services. Typically, an inpatient stay happens when a person’s symptoms are acute, meaning there is a sudden onset, dramatic change, or worsening of symptoms. Examples necessitating an admission include a crisis that impairs your ability to function or if your behavior puts yourself or others in danger. Any diagnosis of severe mental illness requiring intense treatment and round-the-clock specialized care will require inpatient services.
Outpatient services mean you are a patient but “outside" of a hospital setting. These services are covered under Medicare Part B. Outpatient care can range in intensity from minimal therapy to partial hospitalizations. Your doctor will need to certify you meet medical necessity requirements for partial hospitalizations. A person who meets the criteria for a partial hospitalization will attend a daily program but can go home at night. Typically, these programs are offered at hospital outpatient departments or specialized community mental health centers.
Inpatient mental health covered by Medicare
Mental health emergencies require admission to a general or psychiatric hospital. Depending on the severity of the diagnosis and the presence of other complicating factors like substance abuse, inpatient stays can last a few days to months. Sometimes, a person will seek help at a general hospital and be transferred to an inpatient psychiatric hospital.
Part A coverage is limited to benefit periods similar to any other inpatient stay, but mental health differs because it does have a lifetime maximum of 190 days of inpatient psychiatric care. There is no maximum if you receive care in a general hospital but not all general hospitals can accommodate all mental illnesses.
If you have a Medigap or Medicare Advantage plan, you may be eligible for additional coverage over 190 days, but you will need to check for your plan for your specific benefits.
What inpatient mental health services does Medicare cover?
Medicare Part A will cover medically necessary costs for your inpatient stay. Stabilizing medical interventions include diagnostic testing, lab work, specialist consults, medications, and nursing care. During an inpatient admission, doctors aim to establish a safe, effective treatment plan until the patient is considered well enough to discharge home or to a lower level of care.
Severe depression, suicidal thoughts or attempted suicide, self-harm, psychosis, hallucinations, and schizophrenia are common examples of conditions requiring intense treatment.
Deductibles, copays, and benefit limitations still apply, and the longer the admission, the more you will pay out of pocket.
What will you pay for inpatient mental health?
Part A inpatient benefits are organized per “benefit period’ starting the day you are admitted to a skilled nursing facility or a hospital ( general or psychiatric) and ending once you do not need inpatient care for 60 consecutive days. Importantly, benefit periods are unlimited, so you will have more than one benefit period per year if your health needs are high.
For each benefit period, you are responsible for the following:
- $1600 deductible.
- 20% of the Medicare-Approved amount for services rendered by doctors or other mental health providers while you are inpatient.
- Days 1–60: $0 per day.
- Days 61–90: $400 copay per day.
- Days over 91: $800 copay per day for every lifetime reserve day.
You have 60 total lifetime reserve days, which decrease for every inpatient day over 90. If you use all your lifetime reserve days, you will pay all costs for any subsequent stay after 90 days.
Outpatient mental health covered by Medicare
Visits to specialized mental health care professionals in offices, outpatient departments, or community mental health centers are covered under Medicare Part B. The following are the types of providers that Medicare will cover:
- Nurse practitioners
- Clinical nurse specialists
- Clinical psychologists
- Clinical social workers
- Physician assistants
- Psychiatrists and other doctors
Your provider must accept Medicare assignment as payment for services under Part B.
What outpatient mental health services does Medicare cover?
Medicare Part B helps cover outpatient medical bills. Services provided outside a hospital admission include:
- A one-time “Welcome to Medicare” Preventive visit within your first 12 months enrolled in Part B. Your provider will review your risk factors for depression and any mental health history within a thorough, comprehensive visit.
- One yearly “Wellness Visit” where you can talk with your doctor about any changes or concerns to your mental health.
- One yearly depression screening. This must be done by your primary care doctor so proper follow-up and referrals can be made as necessary.
- Diagnostic testing.
- Psychiatric evaluation when needed.
- Management of medications and some prescription medications a provider must administer.
- Reassessment and testing to determine if current treatments and services are helpful for you.
- Psychotherapy in a group or individual setting when directed and led by state-regulated professionals.
- Family counseling specifically to support your mental health.
- Partial hospitalizations are community or hospital day programs that help people avoid inpatient admission.
What will you pay for outpatient mental health?
In 2023, the Medicare Part B deductible is $226. Once you meet the deductible, Medicare will cover 80% of the covered benefits; the remaining 20% is your responsibility. If you have supplemental insurance or a Medigap plan, your 20% coinsurance may be paid. Any additional coverage with Medicare Advantage varies by plan.
You will not owe any fees for a yearly depression screening if your physician accepts payment from Medicare. If your provider recommends you receive care through a partial hospitalization program, there can be additional copays and coinsurance costs. Consulting with your doctor and a Medicare representative can help you determine out-of-pocket responsibilities.
Mental health services not covered by Original Medicare
Original Medicare does not cover conveniences that are not medically necessary. During an inpatient stay, private duty nurses, televisions, phones, and personal care items are not eligible. Private inpatient rooms are only a benefit if they are medically necessary.
As an outpatient, your doctor may recommend more treatment sessions than Medicare Part B allows. If you participate in a partial hospitalization program, Medicare will not compensate meals, transportation, and job training.
Medicare Advantage plans typically provide additional mental health coverage. If you manage a chronic mental illness and have the potential for prolonged psychiatric inpatient stays, these plans may help with costs.
If Medicare beneficiaries exhaust benefits because of long-term psychiatric hospitalization, enrolling in Medicaid can help pay medical bills. Specific eligibility requirements for Medicaid vary by state.
Does Medicare cover mental health prescription drugs?
Original Medicare Parts A and B do not cover drugs prescribed outside certain mental health settings. Part A will cover medications during an inpatient stay, and Part B will cover some injections or infusions that require your provider to administer them in an office. Generally, you will need a Medicare Part D plan for prescription drug coverage. Medication coverage can be complicated, and you may pay a penalty if you do not sign up for a prescription drug plan at the time of initial Medicare enrollment.
Medicare does not cover all medications, often changing the drugs they provide because of advancements or changes to medicine development. Doctors often prescribe medications, such as antidepressants, antipsychotics, and anticonvulsives, as part of treatment plans. Medicare Part D will cover most of these drug categories with some exceptions.
Does Medicare cover mental health benefits?
Medicare Parts A and B cover inpatient and outpatient mental health benefits. Factors such as if your provider accepts Medicare assignments, the type of facility where you receive care, and the duration of treatments can affect your portion of the bills. Prescription medications are covered under Part D, but not every type of drug is eligible.
How many mental health therapy sessions does Medicare cover?
When sessions are received in hospital settings mental health therapy sessions are covered as part of an inpatient treatment plan. Partial hospitalization still offers intense treatment, but not as intense as an inpatient admission. Therapy is an important component; therefore, occupational therapy and individual training designed to help you understand your condition may be covered.
How many outpatient mental health sessions does Medicare cover?
Medicare plans may not cover all your outpatient mental health sessions. If your doctor feels you need more treatment than Medicare allows, you will owe more money out of pocket. Enrolling in Medigap or Medicare Advantage plans may provide you with additional coverage.