Medicare pays for both inpatient and outpatient mental health care, including the cost of therapy. Some out-of-pocket expenses may apply.
Medicare is a federal insurance program for people aged 65 and older or those below age 65 with specific health conditions.
Medicare does provide coverage for therapy, as well as for other mental health care needs. Medicare Part A helps cover hospital stays. Medicare Part B helps cover doctor visits and day programs in a hospital. A person uses Medicare Part D to pay for medications.
In this article, we discuss how a person may get mental health services through Medicare, what the out-of-pocket costs are, and how to get extra help.
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.
A person’s mental health includes their mental, emotional, and social well-being. These functions affect feelings, thoughts, and actions, including how a person manages stress and makes friends.
Mental health is important in every stage of life, and life events can trigger both physical and emotional responses. Some triggers may include:
- losing a job
- retirement
- grief and loss
- violence
- bullying
- loneliness and isolation
Some factors that affect mental health are family history, biology, nutrition, problems sleeping, and physical health.
Nearly
Early signs may help to identify that healing or treatment could be required. Some of those signs include:
- eating too little or too much
- low energy levels
- feeling helpless or hopeless
- yelling and fighting
- mood swings
- sleeping too much or not enough
- unexplained aches and pains
- thoughts of harming
- smoking, drinking, or using recreational drugs more than usual
When a person first enrolls in Medicare, they receive a Welcome to Medicare preventive visit. During this visit, a doctor reviews risks of depression.
Yearly wellness visits can then include discussions with a person’s doctor on any changes to mental health that may have occurred since the last visit.
In addition to the wellness visits, Medicare covers certain mental health services both inside and outside of a hospital.
Part A coverage
Medicare Part A pays for inpatient care a person receives when they are admitted to either a general or psychiatric hospital.
In a psychiatric hospital, Part A only covers eligible costs for up to a maximum of 190 days per lifetime. There is no limit to the number of benefit periods for mental health care received in a general hospital.
Part B coverage
Medicare Part B pays for one depression screening each year. The screening must happen in the office of a primary care doctor or similar to ensure there is appropriate follow-up care.
Part B also pays for single or group therapy by state-licensed experts. Family therapy may be covered when it is to help with a person’s treatment.
Mental health services are covered when provided by:
- a psychiatrist
- clinical psychologists
- clinical social workers
- clinical nurse specialists
- a nurse practitioner
- a physician assistant
Other mental health support services are covered by Part B, including:
- tests to see if current treatment is working
- evaluation and prescription drug follow-up visits
- some prescribed medication that is given in the doctor’s office
- diagnostic tests
- partial hospitalization
Partial hospitalization is a structured day program that replaces inpatient care, with treatment being more intensive than a weekly office visit.
Medicare may pay for partial hospitalization at a community mental health center when the center meets certain rules. The center must offer 24-hour emergency care and clinical evaluation.
During partial hospitalization Medicare does not cover:
- meals
- transport
- support groups (group therapy is covered)
- job skills testing or training that is not part of treatment
Medicare parts A and B do not cover prescribed medication taken at home, but a person can use Medicare Part D to help pay for these costs.
Some services are not eligible for Medicare coverage. These include:
- adult day health programs
- biofeedback
- marriage counseling
- pastoral counseling
- environmental modifications
- preparing reports
- explaining results or data
- schizophrenia hemodialysis
- transport and meals
- phone applications or services
There are some out-of-pocket costs for mental health care.
Additional expenses for Medicare Part A include:
- A $1,408 deductible in 2020 for each benefit period
- 20% coinsurance for approved costs after the deductible has been met
- copayments of:
- $0 for days 1-60 in each benefit period
- $352 for days 61-90 in each benefit period
- $704 for each lifetime reserve day used from day 91
- all costs after lifetime reserve days have been used in full
A person has 60 lifetime reserve days to use during their lifetime.
In Part B, there are out-of-pocket costs for diagnosis and treatment.
A person must pay 20% of the Medicare-approved amount after the Part B deductible is met.
The Part B deductible for 2020 is $198. This amount can change each year.
There are programs available if a person should need additional support with extra costs.
Program of All-Inclusive Care for the Elderly (PACE)
Medicare and Medicaid manage this program that helps people meet their healthcare needs within the community. A team of community healthcare providers from a PACE center organizes care for individuals.
Medicaid
People who qualify for Medicaid may have access to support services in their area. This includes case management, home care, personal care, and transport to doctor appointments.
Extra Help
This program provides help for people with limited resources to pay for prescribed medication. To qualify, a person must prove they get needs-based benefits like Medicaid or Supplemental Security Income (SSI).
Medicare Part A helps cover the hospitalization costs of mental health care, whilst Part B helps pay for therapy and partial hospitalization costs.
Medicare also covers a yearly mental health screening with an approved Medicare health expert.
Original Medicare does not pay for meals, transport, or most prescribed drugs. A person needs Medicare Part D to cover prescription medication.
An individual may have to pay a deductible, coinsurance, or copayment towards mental health care costs but there is help available through programs like Extra Help, Medicaid, or PACE.