Mental Health Coverage with Medicare

Medicare offers some coverage of mental health services, including visits with Medicare-approved clinicians to treat concerns such as depression and anxiety and preventive visits to assess whether further treatment is needed.

In recent years, society has begun to recognize the importance of mental health to overall well-being. Medicare Part B will cover many of your mental health services. Whether you have Original Medicare or a Medicare Advantage plan, Part A and Part B provide the same coverage.

For starters, Medicare Part B — commonly known as “medical insurance” — fully covers several preventive services that can help assess the state of your mental health to see if you have a condition that qualifies for coverage.

• Part B allows you to get one depression screening per year. The screening is provided at no cost to you if it’s performed in a primary care setting (such as a doctor’s office) by a Medicare-approved clinician who can either provide further treatment if needed or refer you to someone else for further treatment.
• Part B also fully covers the cost of an annual wellness visit that can assess your mental health. A similar “Welcome to Medicare” preventive visit is fully covered during your first 12 months of Part B coverage.

Note: As with all preventive treatment offered by Medicare, if a covered visit goes beyond assessment and includes treatment, that portion of the visit could be labeled as “diagnostic” and lead to you possibly being responsible for related costs.

Even if you haven’t taken advantage of preventive services related to mental health, you still may be asking yourself, “Does Medicare cover mental health counseling?”

Preventive services provided by Medicare Part B can help identify issues with mental health, but that’s only one part of the equation. Part B covers a lengthy list of outpatient mental health services administered by Medicare-approved professionals to assist with depression, anxiety and the like:

• Individual and group psychotherapy with doctors or certain licensed professionals allowed by the state where you get the services.

• Family counseling, if the primary purpose is to help with your treatment.

• You are testing to find out if you’re getting the services you need and if your current treatment is helping you.

• Psychiatric evaluation.

• Medication management.

• You need certain prescription drugs that aren’t usually “self-administered” (drugs you would normally take on your own), like some injections.

• Diagnostic tests.

• You need treatment for alcohol and drug use.

• Partial hospitalization for covered services.

Does Medicare Pay for Psychiatric Visits?

The word “psychiatric” is defined as something “relating to mental illness or its treatment.” Medicare mental health coverage does include psychiatric visits.

As is the case with most services covered by Part B, Medicare pays 80 percent of approved mental health services after you meet the Part B annual deductible. You pay 20 percent of the cost for approved mental health services.

Some Medicare mental health coverage may fall under Part A of Original Medicare. When that is the case, Medicare Part A pays the same way it pays for other covered items.

Part A, commonly known as “hospital insurance,” will cover the hospital-related portion of Medicare-approved mental health services that require inpatient hospitalization. Medicare Part A will cover 100 percent of hospital-specific costs for the first 60 days of a stay — after you pay the deductible for that benefit period. You must pay coinsurance for Days 61-90, and your daily coinsurance rate increases if you stay beyond Day 90 and begin using your 60 “lifetime reserve days.”

For expenses during the hospital stay that fall under Part B — first among them, the doctors’ services themselves — Part B as is customary, pays 80 percent after your annual deductible.

While Part A will cover unlimited benefit periods for mental health in a hospital setting, lifetime days in a psychiatric hospital are limited to 190.

Inpatient stays in a psychiatric hospital follow the same coverage rules as any other hospital stay (you pay the benefit period deductible; Part A pays for Days 1-60; you pay coinsurance for additional days). But for your lifetime, Medicare Part A limits you to a total of 190 days in a psychiatric hospital. After Day 190, Part A doesn’t help with any psychiatric hospital costs.

What is “partial hospitalization” for mental health?

Part B of Original Medicare may cover partial hospitalization, which Medicare defines as a structured outpatient treatment that is “more intense than the care you get in a doctor’s or therapist’s office. You get this treatment during the day, and you don’t have to stay overnight.”

Part B may cover occupational therapy and individual training and education about your qualifying condition as part of the covered treatment at a hospital’s outpatient department or community mental health center. It won’t cover related transportation or meals.

How can Original Medicare beneficiaries get more financial assistance for mental health?

While Part B is the part of Original Medicare that most often assists with expenses related to a mental health condition, Part A can be helpful for a couple of reasons.

As previously stated, Part A helps with coverage if you have a mental health issue that requires hospitalization. Part A also can work in conjunction with Part B to control out-of-pocket expenses related to mental health by opening the door for you to enroll in a Medigap supplemental plan provided by a private insurance company.

As the name suggests, Medigap plans fill in some of the gaps in Original Medicare coverage. Among the 10 Medigap plans that provide standardized supplemental coverage, all pay at least 50 percent of Part B coinsurance and copays (eight pay 100 percent).

Alternatively, having Part A and Part B of Original Medicare qualifies you to switch to Medicare Advantage plan. Also provided by private insurance companies with guidance from the federal Medicare program, Medicare Advantage plans replace Original Medicare while providing the same coverages as Parts A and B and possibly additional coverage for things like mental health.

Medicare Advantage plans come in many shapes and sizes. Still, one constant is an out-of-pocket maximum that defines the most money you can have to pay out of pocket in a plan year (Original Medicare doesn’t have an out-of-pocket maximum, although two Medigap plans do).

All Medicare Advantage plans must provide at least the same coverage for mental health as Original Medicare does, but many Medicare Advantage plans offer additional coverage for mental health. If that’s a priority for your healthcare journey, a GoHealth licensed insurance agent can help you identify a Medicare Advantage plan that fits your needs.