What Services Are Included In The Medicare Mental Health Benefits
Medicare mental health coverage is available in an inpatient or outpatient setting, depending onwhich is medically necessary for your treatment. The following services areexamples of whats covered by Medicare for people who need to be treated in aninpatient setting:
- Lab tests
Some of the services available to people inoutpatient care include:
- Lab tests
- Some medications, ifgiven in a medical setting
- Visits with a doctor orsocial worker
Theseare just a few examples of the services that Medicare offers. Medicare alsooffers an annual depression screening, which you can schedule this with yourprimary care physician at your convenience.
Does Medicare Cover Prescription Drugs For Mental Health
Stand-alone Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans can vary in both costs and which drugs are covered. To find out if a medication you need is covered by a specific Medicare plan that offers prescription drug coverage, check the plans drug formulary, which is a list of medications covered by the plan. The formulary may change at any time. You will receive notice from your plan when necessary.
Medicare Part D covers prescription drug benefits you may need for treatment of your condition. Original Medicare, Part A and Part B, doesnt include drug coverage, although Medicare Part B covers some medications that cant be self-administered, such as drugs given by injection. For other prescription coverage, however, beneficiaries with Original Medicare must enroll in a separate Medicare Part D prescription drug plan. Medicare Advantage enrollees can get drug coverage through a Medicare Advantage Prescription Drug plan, which includes Medicare Part A, Part B, and Part D benefits under a single plan.
Certain drugs that treat mental health conditions are in protected classes under Medicare Part D, including antipsychotic drugs, antidepressant drugs, and anticonvulsant drugs. With some exceptions, Medicare Part D prescription drug plans must cover most medications in these drug classes.
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How Much Does Medicare Pay For Mental Health Care Services
An annual depression screening is free if the doctor accepts Medicare assignment. Otherwise, Medicare Part B pays 80 percent of the Medicare-approved amount for most covered mental health care services. You are responsible for the remaining 20 percent, and the Part B deductible applies.
Medicare Advantage plans also help pay for mental health care services and may cover additional mental health services or items. Check with your plan provider to get coverage and cost details.
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Coverage Amounts And Co
While some services are covered fully, such as depression screenings, others may require the beneficiary to pay 20% of the Medicare-approved amount. That includes visits to a healthcare provider to diagnose mental health conditions. Services that are provided by hospital outpatient services may be subject to additional co-pays.
Co-pays can be reduced by combining Medicare with other insurance plans.
Q: Does The Affordable Care Act Require Insurance Plans To Cover Mental Health Benefits
Answer: As of 2014, most individual and small group health insurance plans, including plans sold on the Marketplace are required to cover mental health and substance use disorder services. Medicaid Alternative Benefit Plans also must cover mental health and substance use disorder services. These plans must have coverage of essential health benefits, which include 10 categories of benefits as defined under the health care law. One of those categories is mental health and substance use disorder services. Another is rehabilitative and habilitative services. Additionally, these plans must comply with mental health and substance use parity requirements, as set forth in MHPAEA, meaning coverage for mental health and substance abuse services generally cannot be more restrictive than coverage for medical and surgical services.
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Does Medicare Cover Substance Abuse Treatment
Mental health conditions and substance abuse can often go together, according to the Centers for Disease Control and Prevention. When your provider determines you require reasonable and necessary professional treatment for substance abuse, Medicare might cover both outpatient and inpatient care. Coverage may include diagnosis and treatment, patient education, and psychotherapy.
As with mental health services, Medicare Part A may cover hospitalization for substance abuse. Medicare Part B may cover outpatient care at a clinic or hospital. If you are enrolled in a Medicare prescription drug plan, your medications might be covered. Medicare prescription drug plans are required to cover medications necessary to treat substance use disorders.
Q: How Do I Find Out If My Health Insurance Plan Is Supposed To Be Covering Mental Health Or Substance Use Disorder Services In Parity With Medical And Surgical Benefits What Do I Do If I Think My Plan Is Not Meeting Parity Requirements
Answer: In general, for those in large employer plans, if mental health or substance use disorder services are offered, they are subject to the parity protections required under MHPAEA. And, as of 2014, for most small employer and individual plans, mental health and substance use disorder services must meet MHPAEA requirements.
If you have questions about your insurance plan, we recommend you first look at your plans enrollment materials, or any other information you have on the plan, to see what the coverage levels are for all benefits. Because of the Affordable Care Act, health insurers are required to provide you with an easy-to-understand summary about your benefits including mental health benefits, which should make it easier to see what your coverage is. More information also may be available via the Mental Health and Addiction Insurance Help consumer portal prototype and with your state Consumer Assistance Program . Additional, helpful information on what you can do to better understand the parity protections you have is available in Know your Rights: Parity for Mental Health and Substance Use Disorder Benefits.
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More About Medicare Part B And Mental Health Coverage
As for Medicare Part B, it helps cover the costs tied of mental health treatment outside of a hospital. It pays for care that takes place in a clinic, a community mental health center, or in a doctors or therapists office.
It also pays for care provided by a hospitals outpatient department.
Here are a number of specific outpatient services Medicare covers:
- Annual depression screenings
- Prescription drugs you can’t or usually don’t take on your own
- Diagnostic tests
- Partial hospitalizations
For more information on which outpatient services Medicare covers and which ones it doesn’t, visit medicare.gov.
Keep in mind you may have to pay deductibles or coinsurance for this kind of outpatient care.
Also, Medicare only covers care provided by physicians and practitioners who accept assignment. To accept assignment, a provider has to agree to be paid directly by Medicare. They’ve also got to accept the amount Medicare approves for the treatment in question. And they can’t bill patients for more than the Medicare coinsurance and deductible.
You should always make sure your provider accepts assignment before you make an appointment with them.
How To Get Help Paying For Mental Health Care With Medicare
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Does Medicare Pay For Inpatient Mental Health Care
Inpatient mental health care administered at a general hospital or psychiatric hospital is covered by Medicare Part A.
There is no lifetime limit to the number of days a Medicare beneficiary can receive covered mental health treatment during inpatient hospital stays at a general health hospital.
When treated at a psychiatric hospital, Medicare coverage of mental health care is limited to 190 days over the course of your lifetime.
If you receive inpatient care that is covered by Medicare, you will be responsible for the Medicare Part A deductible, which is $1,408 per benefit period in 2020. If your inpatient hospital stay lasts longer than 60 days, youll then be required to pay additional Part A coinsurance costs.
Does Medicare Cover Psychologist Visits
Clinical psychologists diagnose and treat mental, emotional, and behavioral disorders and are one of the health care providers covered by Medicare Part B.
Coverage: Medicare pays 80 percent of the Medicare-approved amount. You pay 20 percent of the Medicare-approved amount, the Part B deductible, and coinsurance costs. Check that your psychologist accepts assignment or is in your insurance providers network, otherwise Medicare will not pay for the services.
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About the Author: Lynette Chen is a blogger and Medicare Advantage provider at Clever Care. She provides health coverage to individuals, paying for typical expenses such as doctor visits, hospital visits, dental care and nursing services. Visit to find out the most affordable Medicare Advantage plan covers.
Medicare Part D And Prescription Drug Coverage
Medicare Part D are plans run by private companies approved by Medicare. Since each plan can vary by coverage and cost, its important to know the details of your plan and how it applies to medication for mental health care.
Most plans have a list of drugs the plan covers. Although these plans are not required to cover all medications, most are required to cover medications which may be used for mental health care, such as:
If your doctor prescribes a drug that yourplan doesnt cover, you canask for coverage determination and/or an exception.
Mental health care services typically not included under Medicare parts A and B are:
- private room
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Which Outpatient Mental Health Care Services Does Medicare Cover
Medicare covers the following outpatient mental health care services:1
- Family counseling, when the goal is to help with treatment
- Psychiatric evaluation and diagnostic tests
- Outpatient treatment programs
- Medication management and certain medications that are not self-administered, like some injections
- For treatment of drug or alcohol abuse
- Partial hospitalization
What Happened To Parity
More confounding is the fact that Section 123 of the bill applies only to mental health treatment and not to patients seeking other medical services. Provider reimbursement for mental health services is being predicated on this requirement, in spite of the Mental Health Parity and Addiction Equity Act and years of work to establish mental health parity.
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Why Restrict Access To Care During A Behavioral Healthcare Provider Shortage
While nearly all of the changes that have been made by the federal and state governments to expand telehealth as a result of the pandemic have been helpful in making telehealth more widely available to deliver medical care, section 123 appears to be illogical and care blocking action to behavioral healthcare. Further, with the shortage of mental health providers, especially at this critical juncture with the pandemic creating increasing levels of depression, anxiety, grief, and suicide, counselors are needed more than ever to assist those of the 62 million Medicare beneficiaries in need of mental health care.
An article in the New York Times, February 17th titledNobody Has Openings: Mental Health Providers Struggle to Meet Demand describes how overloaded behavioral health providers have become since the pandemic began. Many are not able to take on new clients and waiting lists stretch out months for many providers. Read the full story here. By passing the Mental Health Access Improvement Act, and allowing the well over 100,000 licensed counselors and marriage and family therapists to render services to Medicare beneficiaries, legislators have an opportunity to create significant gains in access to mental health care for millions of Americans.
Medicare’s Coverage Of Mental Health Services
- May 29th, 2021
Some aspects of aging can take a mental toll on the elderly as well as a physical toll. The cost of outpatient mental health services can be steep, but Medicare will cover a portion of the cost.
After you pay your deductible, Original Medicare will pay 80 percent of the cost for outpatient visits to mental health professionals. If you have a Medigap policy, it may cover the additional 20 percent.
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The following are some of the services that Medicare covers:
- Visits to a psychologist or other professional counselor
- Family therapy as long as the focus of the therapy is on the Medicare recipient, not the family
- Substance abuse treatment
- Occupational therapy that is part of mental health treatment
- Prescription medicine that cannot be self-administered
- Art, dance, and music therapy if it is provided as part of a program to prevent the recipient from being admitted to the hospital
Services must be provided by doctors, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, or physician assistants. Medicare will pay for services only if they are provided by a mental health professional who accepts Medicare payments, so check with your health professional before you receive services.
If you have Medicare Advantage, coverage rules may be different, so check with your plan before receiving services.
For more details on Medicare’s mental health coverage from Medicare.gov, .
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How Much Does Medicare Pay For Mental Health Counseling And Other Services
WhileMedicare offers many mental health services, it doesnt usually cover theentire costs. Original Medicare alone typicallyonly pay up to 80% for your inpatient or outpatient services, excluding othercharges like copays and deductibles. Original Medicare also doesnt typicallycover your prescription medications. There are several solutions to helpcontrol your costs:
- Medicare Supplement Plans: Medicare Supplement plans come in a range of coverage options, and help cover the gaps in the services that Medicare pays for. For instance, if you have Medicare Supplement Plan G, you may have no other out-of-pocket costs after you pay your yearly deductible, which is $203 in 2021. Youre able to keep Medicare as your primary coverage, but they dont offer any prescription coverage.
- Medicare Part D Prescription Plans: These plans help cover the costs of your prescription medications. They vary in coverage by carrier and zip code, and your costs may also change depending on which pharmacy you receive your prescriptions from.
- Medicare Advantage Plans: Medicare Advantage plans are primary instead of Medicare. Some of them offer prescription coverage, and they may reduce your out-of-pocket costs for mental health services compared to Original Medicare alone. If you have a Medicare Advantage plan, you should refer to it directly for details on costs and coverage.
What Youll Pay For Inpatient Mental Health Care
A deductible of $1,484 applies to inpatient psychiatric care for each benefit period. You will owe no coinsurance for the first 60 days of a hospital stay for psychiatric treatment. But you will owe copays of 20% of the Medicare-approved amount for mental health services you receive from doctors and other providers while you’re an inpatient.
For days 61 through 90 of a psychiatric hospital stay, youll owe $371 per day in coinsurance. Your daily coinsurance jumps to $742 per each lifetime reserve day after day 90. After that, you pay all costs.
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How Much Will Medicare Pay For Mental Health Services
Medicare will pay a portion of a designated Medicare-approved amount for mental health services provided by licensed professionals who accept Medicare assignments. You are responsible for copays, coinsurance, deductibles, and any amount charged for the service that is higher than the Medicare-approved amount.
Mental health services, such as individual counseling provided in an outpatient setting, will be covered at 80% of the approved charge with Medicare Part B after the annual deductible is met. You pay the other 20%. If you have an MA plan, you will pay a copay, typically ranging from $20 to $40 per session, to see an in-network provider. Deductibles may apply, and your MA plan will cover the rest of the contracted in-network cost.
MA plans must provide mental health services as a Medicare-covered service. Any out-of-pocket expenses you incur in the form of copays count toward your maximum out-of-pocket limit set by your MA plan.
If you receive inpatient mental health services that require hospitalization under Part A, you will be responsible for the deductible .
Alternatively, if you are in a MA plan, you pay a daily copay for days one six for each admission. In 2021, for instance, if you have a UnitedHealthcare MA HMO plan, your daily copay is $225. If you have a similar type of plan with Humana, your daily copay is $190. And if you have a similar plan with BCBS/Anthem, your daily copay is $270. See each plans Evidence of Coverage for more details.