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Does Medicare Cover Psychological Services

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Ann Kayrish Senior Program Manager For Medicare At Ncoa

Medicare Coverage and Payment of Cognitive Assessment & Care Plan Services

Theres been an ongoing issue that folks cant seem to get a professional who accepts Medicare as payment for the mental health counseling and services they do deliver

The good news is that the demand and need for mental health services during the pandemic, prompted Medicare to approve telehealth services for mental health counseling, expanding the pool of accessible professionals. During the public health emergency, you can have an audio only type of visit with a mental health professional and that would be covered by Medicare, says Kayrish, noting that the visits may still require out-of-pocket costs.

Does Medicare Cover Inpatient Mental Health Care

If your condition requires an inpatient stay, Medicare Part A covers general hospital and psychiatric hospital services. Thereâs a cap on Medicare coverage for inpatient services if you stay at a psychiatric hospital : Medicare Part A will only cover psychiatric hospital care for up to 190 days in your lifetime. Even when youâre admitted to a hospital as an inpatient, Medicare Part B covers doctor services you get during your hospital stay.

Does Medicare Cover Outpatient Health Services

Part B will cover routine doctor visits for mental health. Coverage allows you to see clinical psychologists, psychiatrists, social workers, counselors, and other health professionals.

Like Part A, deductibles and coinsurances will apply. Yet, annual depression and alcohol abuse screenings are free.

You may obtain treatment in a therapists office or in a clinic. Further, Medicare will cover activity therapy, such as dance, art, or music therapy. Although, you may need to apply for reimbursement on activity therapy.

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Original Medicare Versus Medicare Advantage

Nearly half of Medicare beneficiaries are enrolled in Medicare Advantage plans, says Ann Kayrish, senior program manager for Medicare at NCOA, so understanding the difference is important.

Original Medicare is a fee-for-service health plan that has two parts: Part A and Part B . Medicare Advantage plans still provide most of Part A and Part B coverage, but the benefits are covered by the Medicare Advantage Plan, not Original Medicare.

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Medicare generally only covers marriage or couples counseling in a very limited number of cases.

First, Medicare has only been reimbursing marriage and family therapists since 2019, and it currently only reimburses them for services provided to people with a primary substance use disorder diagnosis.

Second, Medicare only covers services linked to a primary psychiatric diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders . So, it wont cover any kind of marriage or family therapy from any kind of provider if it isnt required to treat a mental health condition.

This means that if you want to see a social worker or psychologist to address communication or other relationship issues that arent directly related to a mental health diagnosis, Medicare wont cover it.

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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:

Some of the services available to people inoutpatient care include:

  • 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.

How Does Medicare Work For Mental Health Medications

Medicare Part A and Part B do not cover prescription drugs for mental health. You will need to explore other options for prescription drug coverage.

The two plans for prescription drugs include:

  • Medicare Part D: This provides coverage for prescription drugs at a pharmacy. Your Medicare drug plan should specify which drugs are covered and the costs. This is known as a formulary. Before purchasing Medicare Part D, make sure the drugs you need are on the list.

  • Medicare Advantage: This is a plan from a private insurer. It combines Medicare Part A, Part B, and Part D. These plans usually have limited networks for healthcare providers.

Prescription drug coverage will come with monthly premiums, annual deductibles, and copayments or coinsurance.

Medicare plans cover drugs like:

You can buy both Medicare Part D and Medicare Advantage plans. But there is an exception if the Medicare Advantage plan is part of a health maintenance organization or preferred provider organization .

Some of the factors to consider for selecting a Medicare Advantage plan include:

  • The premiums, copays, and coinsurance, which can vary

  • The healthcare providers in the network

  • The coverage for services and medications

You can shop for Medicare Part D and Advantage plans at Medicare.gov. Youll be able to compare plans, costs, and benefits to help you determine the best plan for your needs.

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Where To Find Help Understanding Medicare

The Centers for Medicare and Medicaid Services offers a tool called the Medicare Care Compare that provides a list of Medicare mental health providers who accept Medicare. You can also call Medicare at 1-800-633-4227 or visit a Medicare local office to get in-person assistance.

Kayrish recommends turning to your State Health Insurance Assistance Program , which aims to provide local, in-depth, and objective insurance counseling and assistance to Medicare-eligible individuals, their families, and caregivers. In addition to giving people an introduction to Medicare and help enrolling, she says many of their volunteer counselors are older adults.

In some ways, if you call and end up talking with someone who is of your peer group, that might make the ability to ask questions about mental health coverage a lot easier, says Kayrish.

What Types Of Mental Health Conditions Does Medicare Cover

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Medicare covers all diagnosis-based mental health conditions. This means that your therapist will need to provide Medicare with a diagnosis of a mental health condition in order to receive reimbursement for their services.

Examples of diagnosable mental health conditions include:

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Medicare And Mental Health Coverage

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 persons 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.

Coverage For Inpatient Services

If you receive mental health care in a psychiatric hospital rather than a general hospital, Medicare Part A will pay for up to 190 days of inpatient psychiatric hospital services during your lifetime. After that, youll spend 100% out of pocket for your care, says Malzone. However, after lifetime reserve days are exhausted, she says options to receive mental health coverage include Medicaid,private healthcare coverage, or a county-specific or local program.

Contact your local community mental health and substance use walk-in clinic to inquire or the county crisis line in your area, Malzone says.

Kayrish notes that current legislation is underway to try to extend the 190 days of coverage.

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Medicare Mental Health Provider List

To see a list of mental health providers near you who accept Medicare, you can visit Medicares Physician Compare page or call 1-800-MEDICARE.

Medicare does cover therapy, but coverage is restricted to specific types of therapy providers. Covered provider types include:

  • Clinical social workers
  • Clinical nurse specialists

However, while Medicare covers all of these provider types in general, professionals in any of these categories can choose to opt out of Medicare reimbursement. If you want to see a professional who has opted out, youll need to use a supplemental plan or pay out of pocket for their services.

So, if you want to pay for therapy using Medicare, check with the provider first to confirm that they have not opted out of accepting Medicare and are a participating or non-participating provider.

What Are Participating and Non-Participating Providers?

Participating providers accept Medicare and always accept Medicares approved amount for their services. They submit a bill to Medicare for your care and you are responsible for 20% of that amount.

Non-participating providers accept Medicare but choose whether to accept Medicares approved amount for services on a case-by-case basis. They can charge up to 15% more than Medicare approves. This means you need to pay as much as 35% coinsurance when you see a non-participating provider.

Does Medicare Cover Inpatient Mental Health Treatment

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You must have Medicare Part A to be covered for inpatient mental health treatment at a general or psychiatric hospital. Medicare will pay for most of your inpatient treatment services. However, you may still owe some out-of-pocket costs depending on your plan and the length of your stay.

Here are the basic costs for Medicare Part A:

  • $252458 premium, if you have one
  • $1,408 deductible
  • 20 percent of all Medicare-approved costs during the stay
  • $0 coinsurance for days 160 of treatment
  • $352 coinsurance per day for days 6190 of treatment
  • $704 coinsurance per day for days 91+ of treatment, through your lifetime reserve days
  • beyond your lifetime reserve days, youll owe 100 percent of the treatment costs

Its important to note that while theres no limit to how much inpatient care you can receive in a general hospital, Part A will only cover up to 190 days of inpatient care in a psychiatric hospital.

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What Youll Pay For Outpatient Mental Health Care

For outpatient mental health care, after you meet the Medicare Part B deductible, which is $233 in 2022 , Part B covers 80% and you’re responsible for 20% of covered services. Its important to note that the mental health professionals you use must accept Medicare assignment that means they agree to Medicares price schedule and will not charge you more.

If you have Medicare Supplement Insurance, or Medigap, your 20% share may be covered by your plan. If you have a Medicare Advantage plan, youll need to check your specific plan to see how much youll pay.

If you receive additional mental health services in hospital outpatient facilities, you may owe additional fees to the hospital.

To get information on your out-of-pocket costs, talk to your health care provider. Your bottom line will depend upon providers charges, the facility type, whether your doctor accepts Medicare assignment and any other insurance you may have.

What Part Of Medicare Covers Mental Health Care

Medicare Part A covers mental health care in an inpatient setting. Part A mental health care is in a general hospital or a psychiatric hospital only for people with mental health concerns. If you get inpatient care in a psychiatric hospital, Part A will cover up to 190 days in a lifetime. There is no limit to the number of benefit periods you can have for mental health care in a general hospital.

Part A covers your room , meals, nursing care , therapy and treatment, lab tests, medications, and other services and supplies you need. Part A does not cover personal items or a phone or TV in your room.

Medicare Part B covers mental health care on an outpatient basis in these types of settings:

  • A doctors or other health care providers office
  • A hospital outpatient department
  • A community mental health center

And from these types of providers :

  • Psychiatrist or another doctor
  • Clinical psychologist, social worker, or nurse specialist
  • Nurse practitioner
  • Physician assistant

Part B helps pay for these outpatient mental health services:

Part D helps cover self-administered prescribed drugs.

Medicare Advantage plans cover all services offered through Original Medicare Part A, Part B, and usually Part D. Copays and coinsurance amounts vary, depending on your plan. Providers and services must be in-network and typically require referrals and prior authorizations before you can receive services.

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Which Mental Health Services Are Covered By Medicare Insurance

Your Medicare mental health coverage may cover a variety of resources and services, including but not limited to the below:1

  • Counseling for Alcohol Abuse
  • Family Counseling
  • Medication management and several non-self-administered prescription drugs
  • One depression screening per year
  • Opioid use disorder treatment2

What Medicare Covers For Outpatient Mental Health Services

Does the Original Medicare Plan Pay for Mental Health Care?

Medicare Part B, which pays doctor bills and related health care expenses, covers many mental health services rendered to patients not admitted to a hospital. Covered costs include:

  • An initial Welcome to Medicare visit that includes a review of your risk factors for depression.

  • One depression screening per year, performed in the office of a primary care doctor or in a primary care clinic that provides follow-up treatment and referrals.

  • Psychiatric evaluation to diagnose mental illness and prepare a care plan.

  • Diagnostic testing.

  • Individual and group psychotherapy or counseling provided by physicians or certain other professionals licensed to do so in your state.

  • Family counseling where the main purpose is to aid in your mental health treatment.

  • Medication management and some prescription drugs that are not self-administered.

  • Partial hospitalization, which typically includes many hours of treatment per week without admission to a hospital.

  • Testing to find out if youre getting the services you need and if your current treatment is helping you.

  • An annual wellness visit with a doctor or other provider to discuss any mental health changes.

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Compare Medicare Advantage Plans That Cover Counseling

For California residents, CA-Do Not Sell My Personal Info, .

MedicareAdvantage.com is a website owned and operated by TZ Insurance Solutions LLC. TZ Insurance Solutions LLC and TruBridge, Inc. represent Medicare Advantage Organizations and Prescription Drug Plans having Medicare contracts enrollment in any plan depends upon contract renewal.

The purpose of this communication is the solicitation of insurance. Callers will be directed to a licensed insurance agent with TZ Insurance Solutions LLC, TruBridge, Inc. and/or a third-party partner who can provide more information about Medicare Advantage Plans offered by one or several Medicare-contracted carrier. TZ Insurance Solutions LLC, TruBridge, Inc., and the licensed sales agents that may call you are not connected with or endorsed by the U.S. Government or the federal Medicare program.

Plan availability varies by region and state. For a complete list of available plans, please contact 1-800-MEDICARE , 24 hours a day/7 days a week or consult www.medicare.gov.

Medicare has neither reviewed nor endorsed this information.

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 $226 in 2023. 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.

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Does Medicare Cover Mental Health

Yes, Medicare covers inpatient mental health services under Part A, and under Part B it covers outpatient mental health services, including evaluation and visits with a mental health provider.

Previously, Medicare charged beneficiaries more for outpatient psychiatric treatment than other physicians services. But in 2008, Congress passed a law that gradually reduced the copayment for those services from 50 percent to 20 percent of the Medicare-approved cost. Now Medicare pays the same share of the cost, 80 percent, for outpatient mental health services that it pays for other Part B medical services.

Medicare Coverage For Inpatient Mental Health Services

Mental Health Services Covered By Medicare

In some cases, inpatient counseling and mental health services are the best options to help you get better. If your doctor recommends inpatient mental health care, Medicare will then cover most of your costs.

Part A pays allowable charges after you pay your Part A deductible. There is a lifetime inpatient mental health benefit of 190 days.

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Limitations To Insurance Coverage For Therapy

In the past, insurance companies routinely placed annual caps on the amount of mental health benefits or severely limited your coverage in other ways. The Mental Health Parity and Addiction Equity Act helped with this. Now, any limits that exist cant be more restrictive than limits placed on your physical health.

However, though ACA-compliant plans, Medicare, and Medicaid provide at least some mental health coverage, non-ACA compliant plans for sale outside the Marketplace arent required to do so. So, check with your insurer to see if any limitations exist. Your policys summary plan description is a good starting point for researching limitations.

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