Does Medicare Cover Mental Health?
Learning about mental health issues and whether Medicare offers coverage for it.
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Millions of people in the U.S. are affected by mental illness each year. According to a 2020 study by the National Alliance of Mental Illness, each year:
1 in 5 (20%) American adults experience mental illness
1 in 20 (5%) American adults experience serious mental illness
1 in 6 (16.67%) American youth aged 6-17 experience a mental health disorder
However, nearly half of the 60 million adults and children living with mental health conditions in the U.S. go without any treatment.
This article will help you understand Medicare, their mental health coverage, the costs involved, and alternative options.
What Is Medicare?
Medicare is a U.S. federal health insurance program for people 65 or older, some younger people with disabilities, as well as people with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
Medicare is made up of Part A, Part B, Part C, and Part D.
You can get Medicare coverage in different ways:
Original MedicareWhen signing up for Original Medicare, you will have access to Medicare Part A and Part B.
Medicare Part A refers to inpatient treatment and hospital care, including hospital stays, hospital treatments, and general nursing costs.
Medicare Part B relates to outpatient medical coverage and includes preventive treatments, doctors’ consultations, scans, and tests.
Medicare Advantage PlansPart C/Medicare Advantage Plans are health plans offered by insurance companies that have contracts with Medicare. These policies cover Part A, B, and D expenses, including costs for hospital care, prescription drug coverage, and doctors’ visits.
Prescription Drug Plans (PDPs)Stand-Alone Part D Plans (Prescription Drug Plans) cover self-administered prescription drugs. For example, medications for high blood pressure, pain tablets, and antidepressants.
Medicare Supplement InsuranceMedicare Supplement Insurance is a health plan for people who have Original Medicare that covers out-of-pocket costs such as deductibles, coinsurance, and co-payments.
What Does Mental Health Include?
Mental health includes our:
Emotional well-being
Psychological well-being
Social well-being
It affects how we think, feel, and act as we deal with life. It also plays a role in how we deal with stress, connect with others, and make decisions.
Mental health is important at every stage of life, from childhood and adolescence to adulthood and old age. It is important to keep your mind healthy at all times.
Source: Unsplash
What Are Mental Disorders?
Mental disorders, or mental illnesses, are conditions that affect your thinking, feeling, mood, and behavior.
They can be occasional or long-lasting (chronic). They can affect your ability to relate to others and function each day.
The 5 most common mental disorders in the U.S. are:
Anxiety Disorders (such as social anxiety, OCD, and PTSD)
Mood Disorders (such as depression and bipolar disorder)
Psychotic Disorders (such as schizophrenia)
Dementia
Eating disorders (such as anorexia and bulimia)
Mental illness does not discriminate. It can affect anyone regardless of their:
Age
Gender
Geography
Income
Social status
Race or ethnicity
Religion or spirituality
Sexual orientation
Background
Cultural identity
Source: Pexels
Does Medicare Cover Preventative Mental Health?
Preventive care can identify patients who are at risk for mental health problems and get them the help they need. This way, potential issues can be addressed before they become more serious.
What Is Preventative Care?
Preventive health care is what you do to stay healthy before you get sick. Preventive care can help you stay healthier and as a result, lower your health care costs.
For example, immunizations or vaccinations are considered preventive care. That’s because they help protect you and those around you from diseases like tetanus, measles, chickenpox, seasonal flu, and COVID-19.
Medicare pays for many preventive services, including screenings to see if you're at risk for certain mental health problems.
Preventative benefits that Original Medicare covers include:
Annual screening for depression: You can get one free evaluation for depression every year as long as your doctor is enrolled in Medicare.
Annual screening for alcohol misuse: People with mental health problems are more at risk of abusing alcohol and drugs. Medicare pays for one alcohol misuse screening per year. All Medicare enrollees who are not alcohol-dependent may get help.
Once-off ‘Welcome to Medicare’ visit: This first preventive visit examines your risk for depression. You'll need to make use of this medical checkup during the first year that you have Medicare.
Annual ‘wellness’ visit: Your doctor will check your physical and mental health, and you'll be able to talk about any mental health issues you may have. Your doctor will give you advice based on your risk factors or send you for treatment if necessary.
Source: Unsplash
What Outpatient Mental Health Services Does Medicare Cover?
As mentioned above, Medicare Part B helps pay for outpatient mental health services. It covers all the preventive services above, as well as all the following outpatient services:
Individual and group psychotherapy with state-approved doctors or licensed professionals.
Family counseling, if its purpose is to help with your treatment.
Testing to find out if you’re getting the services you need and if your current treatment is helping you.
Counseling services: Assessments include, but are not limited to, psychiatric evaluation and diagnostic tests. These are done to help your doctor diagnose or rule out a suspected illness or condition.
Medication management: This includes monitoring and adjusting medications, to ensure patients get the desired outcomes.
Certain prescription drugs that aren’t usually “self-administered,” like some injections.
Partial hospitalization: A structured program of outpatient psychiatric services as an alternative to inpatient psychiatric care.
What Is the Difference between Outpatient and Inpatient Care?
Inpatient care requires that a patient is admitted to a hospital or a registered health care facility, which outpatient care does not.
If you receive inpatient care, you will be monitored by a healthcare team in a hospital throughout your treatment and recovery. Some examples of inpatient care include:
Rehabilitation services
Surgeries
Childbirth
Serious Illnesses that require a patient to be monitored overnight in a hospital
Outpatient care, also called ambulatory care, does not require hospitalization. For example, a visit to the doctor and counseling are considered outpatient services.
Source: Unsplash
What Inpatient Mental Health Services Does Medicare Cover?
Medicare Part A covers inpatient mental health services that you receive in either a psychiatric or a general hospital. Your provider should determine which is more applicable.
What Is a Psychiatric Hospital?
Psychiatric hospitals, also known as "mental health units" or "behavioral units," are hospitals or wards where people with very serious mental illnesses are treated.
These illnesses commonly include schizophrenia, bipolar disorder, and major depressive disorder, among others.
People with other mental illnesses often check themselves in at these facilities to get expert help and assistance. It is not uncommon for people with anxiety disorders, eating disorders, sleep disorders, and other conditions to go to a psychiatric hospital for help.
If you receive care in a psychiatric hospital, Medicare covers up to 190 days of inpatient care in your lifetime.
If you have used your 190 days and need additional mental health care, Medicare may cover your care at a general hospital.
Be aware that regardless of whether you receive care in a general or psychiatric hospital, you will have the same out-of-pocket costs, such as premiums, deductibles, co-payments, and coinsurance.
After meeting your Part A deductible, Original Medicare pays in full for the first 60 days of your benefit period. After day 60, you will pay a daily hospital coinsurance.
Terms You Should Know
Benefit periods for Medicare Part A begin the day you're admitted as an inpatient in a hospital or skilled nursing facility (SNF). It ends when you haven't received any inpatient hospital care or skilled care in an SNF for 60 days in a row.
If you go into a hospital or an SNF after one benefit period has ended, a new benefit period begins. There's no limit to the number of benefit periods.
Unlike Part A, Medicare Part B benefit periods are annual, with the exception of certain preventive care tests. You would be expected to pay 20% of all Part B costs.
Deductibles are amounts that people have to cover before their Medicare plan or insurance starts to pay for medical expenses.
Coinsurance amounts are a part of the costs that beneficiaries must pay for medical treatments, services, and tests.
Co-payments are set amounts or rates that beneficiaries pay for medical services, tests, and items.
If you are admitted to a psychiatric hospital within 60 days of being an inpatient at a different hospital, you are still in the same benefit period and do not have to pay the Part A deductible again.
Source: Unsplash
Does Medicare Cover Prescription Drugs for Mental Health?
It isn't required that Medicare Part D (Prescription Drug Plans) have to cover all drugs, but with a few exceptions, they are required to cover all medicines that treat depression, psychosis, or seizures.
Part D plans are sold by private insurers and other companies that Medicare has approved.
Almost all plans have a formulary. This list can change each year, but the company has to notify you at least 30 days before a change takes effect.
What Is a Formulary?
A formulary is a list of drugs (both brand name and generic) that are selected by your health plan as the preferred drug to treat certain health conditions.
How Much Does Mental Health Care Cost?
Mental health care costs are quite expensive.
According to Good Therapy, an online therapist directory, an hour-long traditional therapy session can range from $65 to $250 for those without insurance.
A more severe diagnosis, of course, carries heavier lifetime costs. A patient with major depression can spend an average of $10,836 a year on health costs.
These costs also differ for outpatient and inpatient care.
Medicare Mental Health Outpatient Care Costs
For outpatient mental health care, after you meet the Medicare Part B deductible which is $233 in 2022, there are typically co-payments of 20% for additional services.
If you receive additional mental health services in hospital outpatient facilities, you may owe more.
The costs will also depend on:
Your providers’ charges
The facility type
If your doctor is Medicare-approved
Additional insurance you may have
Medicare Mental Health Inpatient Care Costs
Deductibles for inpatient mental health care start at $1,556 and go up for each benefit period. You will not have to pay coinsurance for the first 60 days of a stay in the hospital.
However, you'll have to pay 20% of the Medicare-approved amount for mental health services you get from doctors and other providers while you're in the hospital.
In 2022, if you stay in a psychiatric hospital, for days 61 to 90 you'll pay $389 per day in coinsurance. After day 90, your coinsurance goes up to $778 a day.
For people who have Original Medicare, there are a set number of days that they will pay for you to stay in a hospital. If you're in the hospital for more than 90 days, this set amount of days may cover your stay.
You have a total of 60 lifetime reserve days that can be used during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.
What Is a Lifetime Reserve Day?
Lifetime reserve days are additional days that Medicare Part A will pay for when a beneficiary is in a hospital for more than 90 days during a benefit period.
Where Can I Learn More about Medicare?
If you are looking for more information about Original Medicare, Medicare Advantage Plans, or anything Medicare-related, head to PolicyScout’s Medicare hub to compare your options and find the best plan in your area.
If you are looking for personalized guidance, send your questions to Help@PolicyScout.com or call us at 1-888-912-2132 to get assistance from one of our skilled Medicare consultants.