The partial hospitalization program is available to those who may otherwise need inpatient care for a mental health condition. Original Medicare and Medicare Advantage cover this program.
The program’s costs include a coinsurance for each service that a person receives from a mental health professional. There is also a coinsurance for each day a person spends at the partial hospitalization facility.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Partial hospitalization is a structured outpatient program in which a person can receive psychiatric services.
It provides treatment for people with mental health conditions that severely affect several aspects of their life, including:
- social life and relationships
- education
- vocation
- activities of daily living
The program does not involve recreational or diversionary activities.
A person will undergo an intensive treatment regimen of clinically recognized services, such as:
- occupational therapy
- medications
- patient training and education
- family counseling
- mental health diagnostic services
- individual and group psychotherapy
A doctor will set out and direct a customized treatment plan specific to an individual’s needs. A multidisciplinary team will be responsible for implementing the plan.
The plan’s treatment goals must be medically necessary, measurable, and directly related to the reason for admission.
A person in the program receives a minimum of 20 hours of therapeutic services per week. The treatment occurs during daytime hours and does not involve an overnight stay.
Partial hospitalization is a less intensive option than inpatient psychiatric care, but it is more intensive than outpatient treatment in a therapist’s office.
Common settings for the program are hospital outpatient departments and community mental health centers.
Both original Medicare and Medicare Advantage cover partial hospitalization.
Original Medicare
In original Medicare, Part A provides hospitalization insurance, and Part B provides outpatient medical insurance.
Partial hospitalization coverage falls under Part B for people who are otherwise at risk of needing inpatient treatment and those who need partial hospitalization after an inpatient facility has discharged them.
At times, a doctor may prescribe a service that Medicare only partly covers or does not cover at all. When this happens, a person must pay some or all of the costs.
Medicare Advantage
Medicare Advantage, otherwise known as Part C, is an alternative to original Medicare. It covers all the benefits of parts A and B, including those for partial hospitalization.
However, the costs of the program with Medicare Advantage plans may differ from those in original Medicare.
A person’s mental health involves their emotional, social, and psychological well-being. This aspect of health affects an individual’s thoughts, actions, and feelings. It also influences how a person relates to others, deals with stress, and makes decisions.
According to
- experiencing low energy
- eating or sleeping too much or too little
- feeling hopeless
- withdrawing from people and usual activities
- drinking, smoking, or using drugs more than usual
- having extreme mood swings
- hearing voices
- thinking of harming themselves or others
All parts of Medicare provide coverage. We look at these in more detail below.
Original Medicare and Medicare Advantage
In addition to partial hospitalization, Medicare covers a full range of outpatient mental health services.
These include one screening for depression per year, one “Welcome to Medicare” visit that reviews risk factors for depression, and one yearly wellness visit to discuss mental health changes with a doctor.
Medicare also covers mental health treatment services, such as:
- psychiatric evaluation
- individual and group psychotherapy
- family counseling
- diagnostic tests
- prescription drugs
- medication management
To cover treatment services, Medicare requires a mental healthcare provider to accept assignment, and they must be a professional, such as a:
- psychiatrist
- clinical psychologist
- nurse practitioner
- clinical social worker
Some Medicare Advantage plans may require a person to visit an in-network provider.
Exclusions
There are some exclusions to Medicare’s coverage of mental health services.
While Medicare may cover group psychotherapy sessions, it does not cover general support groups.
Additionally, plans do not cover:
- transportation to facilities providing mental health services
- meals
- vocational training that is not a part of a person’s mental health treatment
Part D
Medicare Part D prescription drug plans cover the take-home medicines that a person may need.
Private insurance companies administer Part D plans, which are available to people with original Medicare.
Each plan contains medications that doctors commonly prescribe for mental health conditions.
Medigap
Private insurance companies also administer Medigap plans.
Medigap is Medicare supplement insurance that pays 50–100% of the out-of-pocket costs of parts A and B, including those related to mental health.
Each part of Medicare has out-of-pocket costs.
Original Medicare
In original Medicare, the yearly depression screening is free. Other costs include:
- the Part B annual deductible of $203 in 2021
- 20% of Medicare-approved charges
- a copay or coinsurance to a hospital if someone gets services from a hospital outpatient department
Medicare Advantage
As with original Medicare, the yearly depression screening is free. Other Medicare Advantage costs include copays, coinsurance, and deductibles, all of which vary among Advantage plans.
Part D
Part D costs include copayments, coinsurance, and deductibles, all of which differ depending on the plan provider.
Medigap
The only expense for a Medigap plan is the premium, which ranges from less than $100 to several hundred dollars per month, depending on the plan provider.
If a person feels as though they need help with their mental well-being, a good first step is to speak with a primary care doctor who can refer them to the appropriate service.
However, some people may not have a primary care doctor. In these instances,
- Anyone experiencing a potentially life threatening situation should call 911 immediately.
- Someone having suicidal thoughts or feelings may call the National Suicide Prevention Lifeline at 800-273-TALK (8255). Trained crisis workers are available to provide counseling and mental health referrals.
- If a person has a mental health condition related to substance abuse, they may call the Substance Abuse and Mental Health Services Administration (SAMSHA) helpline. The number is 877-SAMHSA7 (877-726-4727).
Medicare covers a partial hospitalization program for people with mental health conditions.
The program involves a range of services, such as counseling, medications, and psychotherapy.
Partial hospitalization provides a structured treatment program that is less intensive than inpatient treatment during a hospital stay but more intensive than the treatment that a person would receive from a series of doctor visits.