Before we dive into Medicare’s coverage of mental health care, let’s talk about what mental health care is. Mental health care refers to services and programs intended to help diagnose and treat mental illnesses or mental health conditions. A mental illness or mental health condition affects your thinking, feeling, or mood. Examples of mental health conditions include depression, anxiety, and schizophrenia. Some also consider addiction, like opioid use disorder and alcoholism, to be a mental health condition. It is important to note that mental health conditions are typically not the result of any single event or circumstance. Rather, they tend to be complicated conditions involving multiple factors.
You may also hear the term behavioral health used in certain settings. Behavioral health is a larger umbrella term which also includes mental health and substance use disorders. While there are differences in the terms behavioral health and mental health, they are sometimes used interchangeably, as there is a lot of overlap between the two. In this post, we use the term mental health.
If you or someone you know is having a mental health or substance abuse crisis, call or text 988 to reach the 988 Suicide and Crisis Lifeline.
Now, how does Medicare cover outpatient mental health care?
Medicare Part B covers outpatient mental health care, like individual and group therapy, activity therapies such as art therapy, partial hospitalization programs, and annual depression screenings. Medicare also covers outpatient substance use disorder treatment, such as services you receive from a clinic, hospital outpatient department, or opioid treatment program.
When choosing mental health care providers, make sure they accept assignment so that you avoid paying more. Accepting assignment means that a provider accepts Medicare’s approved amount as full payment for a service. If you see a non-medical doctor, like a psychologist or clinical social worker, it is additionally important that they be Medicare-certified. Medicare will only pay for the services of these types of providers if they are Medicare-certified and accept assignment.
If you have Original Medicare, you owe a 20% coinsurance for most services after meeting your Part B deductible ($226 in 2023). For most preventive services, including annual depression screenings, you pay nothing and do not need to meet your Part B deductible. If you have a Medicare Advantage Plan, contact your plan to find in-network providers and learn about costs.
Medicare may also cover your prescription drugs related to your mental health treatment.
You can get prescription drug coverage through a stand-alone Part D plan if you have Original Medicare, or as a part of your Medicare Advantage Plan. Before joining a prescription drug plan, make sure that drugs you need are on that plan’s list of covered drugs. Part D plans are required to cover many drugs used to treat mental health conditions. This includes all antidepressant, anticonvulsant, and antipsychotic medications, with limited exceptions.
How does Medicare cover inpatient mental health care?
Medicare Part A covers inpatient mental health services. These are services you receive in a psychiatric hospital or general hospital, both for inpatient mental illness treatment and inpatient substance use disorder treatment. Your covered days in a psychiatric hospital have a lifetime limit, but your covered days in a general hospital do not. Medicare covers up to 190 days of inpatient care at a psychiatric hospital in your lifetime. If you have used your lifetime days at a psychiatric hospital but need additional inpatient mental health care, Medicare may cover your care at a general hospital.
General and psychiatric hospitals have the same out-of-pocket costs. After meeting your Part A deductible ($1,600 in 2023), Original Medicare pays in full for the first 60 days in your benefit period. A benefit period begins when you enter a hospital as an inpatient and it ends when you have been out of the hospital or a skilled nursing facility for 60 days in a row. After day 60, you owe a daily amount to the hospital ($400/day for days 61-90 in 2023).
Still have questions?
Your SHIP is here for you! You can contact your SHIP for any other Medicare-related questions or concerns you have. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
Be on the lookout for suspicious mental health care charges
Anyone can experience Medicare fraud and abuse, and it, unfortunately, can increase health care costs for everyone. Medicare fraud and abuse is when someone intentionally gives incorrect information to Medicare or Medicare beneficiaries in order to get payment. For example, you may be experiencing fraud if you and other people with Medicare are bused to a nice meal, and then your Medicare is billed for a psychiatric evaluation. Or perhaps you spend the day at a facility watching TV or playing games, and then your Medicare is billed for group psychotherapy.
Note that fraud and abuse are different from errors. Health care providers and their billing offices sometimes make honest mistakes. If you think your doctor or their billing office made a mistake, contact them directly first so that they can correct the billing error.
Always read your Medicare notices to catch any suspicious charges like these. If you believe you may have experienced Medicare fraud or abuse, contact your local Senior Medicare Patrol (SMP) for help in reporting the incident.
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