Medicare Part B covers a variety of mental health services, including counseling and psychotherapy.
Yes, Medicare does cover counseling services in most cases. Understanding the full range of mental health coverage for varying mental health conditions that you can access under Medicare can seem daunting because there are many specific restrictions and rules to follow. We’ll go over everything you need to know to navigate your mental health benefits with Medicare.
Outpatient Mental Health Coverage: Medicare Part B
Most mental health care is outpatient care, which means that you aren’t admitted to a facility for an overnight stay.
The most popular forms of outpatient mental health services, counseling, and psychotherapy are usually covered by Part B. This includes visits to a clinical psychologist as well as the services you get from clinical social workers, nurse practitioners, and physician assistants.
Medicare also covers one depression screening per year, as well as other counseling services like family counseling and group therapy. For many services, like alcohol misuse screenings, diagnostic tests, and psychiatric evaluations, you will pay nothing.
Part B coverage for counseling and mental health services will function similarly to other things that Part B covers, like doctor visits. If the healthcare provider that you visit accepts assignment, then you will only be charged for your deductible and coinsurance, usually 20 percent, that applies to your visit.
If your mental healthcare provider does not accept assignment, then you may have to pay additional excess charges. You can always ask a provider if they accept Medicare assignment before you visit them.
Partial Hospitalization Program Coverage
Some patients who need additional mental health treatment undergo what is called partial hospitalization. This refers to intensive programs that can take up a good portion of each day, but which don’t require inpatient care. While you may be undergoing treatment for much of each day, you will still go home to sleep and will usually have to take care of your own meals.
Medicare does cover partial hospitalization services but under a few specific conditions. Your doctor will have to note that if you don’t undergo partial hospitalization, they would advise that you participate in an inpatient program. If this is the case, then Medicare will cover the costs of your treatment. However, they will only cover services directly related to your care, not those related costs like transportation and food.
Partial hospitalization can take place at various locations, including community mental health centers, hospitals, or community centers. It will be covered in the same way no matter where it takes place.
Inpatient Care and Hospital Stays: Part A Coverage
Medicare can also cover mental health services that you receive as an inpatient. The coverage is slightly different depending on whether you are admitted to an ordinary hospital or a psychiatric hospital. However, this has to do with how many days are covered, not which services are covered. In general, if you are an inpatient receiving psychiatric care, your care will be covered.
General Hospitals Versus Psychiatric Hospitals: What’s the Difference?
As a Medicare beneficiary, you are entitled to 190 days of inpatient care in a psychiatric hospital. This refers to 190 days total, not per benefit period. Each day that you spend as a psychiatric hospital inpatient will remove one day, and there’s no way to bring them back. These days are similar to the lifetime reserve days that you get under normal Part A hospitalization coverage.
On the contrary, general hospital services are covered per benefit period. You can receive full coverage for 60 days each benefit period, after which you begin to pay a larger coinsurance. These covered days reset with each new benefit period.
Benefit periods are a distinct type of period that Medicare Part A uses. Once you are admitted to a hospital, your benefit period begins. After you’ve spent 60 consecutive days with no hospitalization, your benefit period ends. At this point, a new period will begin next time you are hospitalized.
Psychiatric Prescription Drug Coverage
When it comes to mental health care, drug coverage is a distinct area under Medicare. Drugs are covered by Part D plans, not Original Medicare. This means that if you want prescription drug coverage, you need to get one of these plans -- no exceptions.
Part D plans are offered by private insurance companies, not by the government. This means that unlike Original Medicare, prices and coverage will both vary.
Formularies: The Key to Part D
Part D prescription drug plans will come with something known as a formulary. A formulary is a list of drugs that the plan covers. It usually has tiers, meaning that some drugs will cost more than others. Before you choose which plan to buy, make sure that the drugs you need are on their formulary. If they aren’t, then this plan will be worthless to you.
Medicare Part D plans are required to cover at least some antidepressants and antipsychotic medications. However, the details will vary.
The one exception to this general rule relates to drugs that are not self-administered. If you are receiving one of these drugs, usually intravenously, as part of your mental healthcare program, then it will likely be covered by Part B.
Medicare Advantage and Mental Health Coverage
Medicare Advantage plans, also known as Medicare Part C plans, offer a way of receiving your medical insurance through a private health insurance company, rather than the government. Part C plans, like Part D plans, will vary widely in cost. However, all Part C plans will offer at least the same coverage as Original Medicare.
Some Part C plans will also offer more coverage than Original Medicare. This means that some plans may offer more mental health coverage. Some Part C plans offer prescription drug coverage as well. If the plan you are interested in offers this bundled coverage, make sure to look at the formulary to see if the drugs you need are covered.
Medicare Advantage can also use different cost-sharing methods than Original Medicare. This means that you may have a copayment instead of a coinsurance, or that the percentages can vary from what you are used to under Original Medicare.
Can Medigap Plans Help with Coverage?
Medigap plans, also known as Medicare Supplement plans, are insurance plans that help cover your out-of-pocket costs under Original Medicare. There are many plans to choose from, and each plan will cover different out-of-pocket costs. These plans do not directly cover medical care.
Because your Part B deductible and coinsurance will apply to your mental health coverage, Medigap plans that cover those fees can help lower your overall costs.
Medigap plans are only relevant if you have Original Medicare. They will not help cover out-of-pocket costs associated with Medicare Advantage.
Medicare Benefits for Mental Health: Not So Complicated
As you can see, Medicare counseling and mental health coverage aren't so complicated. Although there are some things you need to be aware of, especially when it comes to prescription drug coverage, Medicare coverage for mental illness is fairly simple.
Just remember to keep track of your plan’s formularies and your benefit periods if you’re receiving inpatient treatment, and you should be good to go.
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