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The World Health Organization reports that approximately 15% of adults aged 60 or older suffer from a mental disorder that is not part of the normal aging process. Frequently, the symptoms experienced are anxiety or depression. Oftentimes, people with these symptoms do not realize that they are very treatable and, coincidentally, do not seek help. So, does Medicare cover mental health? You bet.
Medicare is a valuable resource to beneficiaries when it comes to mental health. In 1965, when Medicare began, everything changed for seniors and their healthcare. Fortunately, today, more than 50 million people can count on Medicare for their medical needs during retirement. This includes need for mental health care.
Medicare benefits are broken down into multiple parts. Let’s look into how Medicare covers mental health care under its various parts.
Medicare Part A provides coverage for your inpatient hospital stays. It also covers skilled nursing facility care, the blood received in a transfusion, and hospice benefits. Included in this part is up to 190 total days in an inpatient mental healthcare clinic within your lifetime.
Additionally, if you have used up your entire 190-day benefit, Medicare may still cover your stay elsewhere as this limit does not apply to psychiatric wards or units in general hospitals. Medicare measures Part A cost-sharing in benefit periods. Whenever a hospital or psychiatric facility admits you, a new benefit period begins. This period continues until you leave the hospital. Once you have stayed 60 consecutive days outside the hospital, the period resets.
Though your Part A Medicare will cover your stay, they will not cover other ‘amenities.’ They will not cover private duty nursing, an in-room phone or television, personal items, or a private room (unless deemed necessary by your physician).
For each new benefit period, you will need to pay your Part A deductible. As of this year 2023, this deductible is $1,600. Cost-sharing does increase should you need to stay in the hospital for an extended period. After 60 consecutive days in the hospital, your daily co-pay will be $400 for each day. After 90 days, that daily hospital co-pay increases to $800 each day. You will now enter your lifetime reserve days.
Reserve days are the days that you continue your stay as a patient beyond the 90 consecutive days covered by Medicare. You only get 60 of these days during your lifetime.
Below is a summary of the above information on what you will pay: (it is important to note these amounts will vary from year to year – numbers are based on 2023)
In the rare case that your hospital stay reaches 150 consecutive days, you will then pay for any and all costs related to your inpatient hospital stay. Remember, a new benefit period begins after you’ve been out of the hospital for 60 days.
Looking at Part B of Medicare as a whole, it provides you with coverage for outpatient services. This includes ordinary things like doctor visits, lab work, diagnostic imaging, preventive care, and x-rays. It also covers more expensive things like ambulance transportation (both ground and air), durable medical equipment (DME), chemotherapy, radiation, and more.
When it comes to mental health, the best way to think of your coverage from Part B is any medical attention you receive in relation to mental health outside of the hospital or inpatient facility that accepts Medicare assignment.
When it comes to mental health, Part B is particularly important when it comes to diagnosing and treating depression. Part B covers a yearly depression screening, which your primary care doctor usually performs. If your doctor diagnoses you with depression or any other mental health condition, Medicare Part B will cover your consultations with a clinical psychologist, social worker, or psychiatrist.
The therapy options you have are flexible with both individual and group counseling. In some cases, family counseling can be approved as part of your personal treatment plan.
In some situations, mental health disorders can be linked to substance abuse problems. These problems can include both drug and alcohol abuse. Each year, Medicare will cover an alcohol misuse screening in the case that you are not dependent upon alcohol.
If your doctor determines that you are abusing alcohol, you can also get up to four counseling sessions under Medicare to help treat your substance abuse issues. There is no cost to you for the screening or counseling.
In some cases, drugs are needed to treat specific drug abuse dependencies, and this sort of treatment would be covered under Part D discussed below.
There are instances that may occur when your doctor decides that you really need a more structured psychiatric program to be given on an outpatient basis. Part B will allow your Medicare doctor to certify your need for this type of treatment. It will then be covered 80% by Medicare Part B.
This sort of program is called a partial hospitalization program. These programs are an option for those who need more specific treatment or overall supervision than what the therapist’s office can offer, yet they are not intensive enough to be admitted to the hospital. This type of program may be coordinated through a mental health facility or hospital. Unlike being hospitalized, partial hospitalization programs do not cover meals or transportation.
Your cost-sharing under Medicare Part B includes a once-per-year deductible along with the other 20% of your outpatient expenses. Unfortunately, there is no maximum limit on what you pay which can lead to high out-of-pocket spending.
Because of this, many individuals decide to enroll in either Medicare supplement insurance coverage or a Part C Medicare Advantage plan to fill in these gaps.
Below is a summary of the above information on what you will pay: (it is important to note these amounts will vary from year to year – numbers here are based upon 2023)
In 2006, Medicare began what is known as Part D. Part D is a voluntary part of Medicare that provides coverage for outpatient prescription drugs. Up until 2006, beneficiaries did not have coverage for retail prescription drugs.
As mentioned above, Part D is a voluntary part of Medicare. Some individuals may not need it if they have alternative drug coverage through an employer insurance plan or through the VA. Since most of the population does not have built-in coverage, Part D was a welcome change.
Medicare Part D plans are required to cover nearly all drugs classified as antidepressants, antipsychotics, and anticonvulsants.
When enrolling, you would find a drug plan offered by an insurance company that offers Part D plans in your home state. Typically, there are dozens of Part D drug plan options in every state. That said, all Part D drug plans have minimum essential requirements.
During the Medicare Annual Election Period, which happens each year in the fall between October 15th through December 7th, you are allowed to make changes to your existing drug coverage. The Medicare website offers a convenient Tool that allows you to find the most cost-efficient plan for you in the next year.
When discussing Part B, we mentioned the scenario where you could pay out-of-pocket copayments with no caps. In other words, there is no limit to how much you may spend on your mental health care needs. That is where a Medigap or Medicare Supplement plan can help.
Medigap and Medicare Supplement Plans are health insurance policies that you can purchase to help pay for some or all of these cost-sharing items. This type of plan then pays after Medicare approves your claim and pays its share. There are 10 different standardized Medigap policies available in most states.
With many different options, Medigap Plan F has consistently been a favorite for many years. Plan F covers all the gaps in Medicare Parts A and B. Plan G has gained popularity more recently as Plan F went away in 2020.
Medicare supplements can be used at any provider that accepts Medicare. However, many psychiatrists do not accept Medicare, so it is important to check with your doctor before beginning any therapy.
Alternatively, another option to help pay for the gaps in Medicare mental health coverage is a Medicare Advantage plan, or Part C. These plans are private healthcare policies that pay instead of Medicare. When you enroll in a Medicare Advantage plan, you’ll generally receive your care from providers that are in that specific plan’s network.
Additionally, many Medicare Advantage plans already include Part D drug coverage that will help to cover your prescriptions.
In all, there have been changes to Medicare over the years that have improved the ability of beneficiaries to receive the appropriate mental health care. Mental health care includes services and programs to help diagnose and treat mental health conditions.
People with Medicare can count on having assistance for both outpatient and inpatient mental health care. Do you need help with finding a Medicare supplement or Advantage plan to fill in the gaps? Contact us today for free assistance.
