Medicare coverage exists to keep you as healthy as possible, and that includes behavioral and mental health as well as medical care.
Medicare offers mental health screenings as part of your standard preventive health care. The first step will typically be your initial “Welcome to Medicare” preventive visit, where you and your doctor discuss your medical and mental health history and status.
As a standard part of the Welcome to Medicare visit, your doctor will ask questions to assess your risk of depression. The most common tool physicians use is the Patient Health Questionnaire, or PHQ-9. The PHQ-9 is a self-reporting instrument, meaning that you fill out a questionnaire and your physician assesses your responses.
Alternatively, your doctor may choose to use the two-question Patient Health Questionnaire (PHQ-2), which evaluates your feelings of depression or hopelessness as well as your overall motivation to engage with life over the most recent two weeks. Unlike the written PHQ-9, the PHQ-2 is usually given verbally.
Medicare covers one depression screening per year. It doesn’t need to take place at your covered annual wellness visit, but it does need to happen at a PCP’s office or primary care clinic that can offer referrals and follow-up care.
Medicare also covers one screening for alcohol misuse each year, provided that you don’t meet the criteria for alcohol dependence. If your doctor feels that you may be misusing alcohol, you qualify for up to four counseling sessions per year.
If any screening indicates that you may have depression or alcohol misuse, or if your doctor suspects other mental health issues at play, you can qualify for treatment. If not, you will qualify for another screening the following year.
Medicare covers select types of mental health care. In general, if the services you receive target your mental health, they are covered under Medicare.
Medicare does cover individual and group psychotherapy and may cover family therapy if the goal is to treat your identified mental health concern. Medicare also restricts coverage to providers who have certain credentials. These are:
Psychiatrists and other physicians
Clinical social workers
Clinical nurse specialists
Medicare does not cover therapy with mental health counselors or pastors, even if those professionals are state-licensed. If you have any doubt as to whether your desired provider accepts Medicare, ask.
If you receive outpatient mental health services through a hospital, you may have to pay an additional copayment or coinsurance. Relatedly, if your doctor recommends that you receive services more frequently than Medicare will cover, you will be responsible for any additional costs.
Medicare Part B, which covers doctors’ visits including those related to mental health, does not cover prescription drugs of any kind. This coverage is available through Medicare Part D or Medicare Advantage plans. It does cover antidepressants and other medications for mental health, but you’ll need to find out whether your specific prescription is covered.
Medicare Part B does cover medication management services, including visits to a licensed prescriber to determine whether you are on the right dose of the right medication. Part B also covers some certain injections and other medications that are not self-administered.
Medicare covers diagnostic testing to help your doctor formulate a diagnosis. Ongoing psychiatric evaluation and testing is also covered and is intended to help you and your doctor evaluate whether you’re getting the right services for your situation.
When a patient needs more mental health care than typical outpatient services provide, partial hospitalization may be an option. Partial hospitalization is an intensive structured day program that can look and feel much like an inpatient program, except that it doesn’t involve an overnight stay.
Medicare covers these services if they take place at a community mental health center or hospital outpatient location. To qualify, your doctor must report that you would otherwise require inpatient care.
Medicare covers inpatient mental health treatment as recommended by a doctor. You can receive these services in the psychiatric department of a general hospital or as part of a dedicated psychiatric hospital.
If you elect to stay at a psychiatric hospital, Medicare only covers 190 days of treatment over your lifetime. There is no limit to psychiatric stays in a general hospital. Limitations related to benefit periods apply in both cases.
Benefit periods are defined as a period of needed care in a skilled nursing facility or hospital. They begin on the day of admission and end when you haven’t received inpatient care for 60 consecutive days.
For each benefit period, your inpatient mental health care expenses will include:
$1,364 in deductible costs
$0 daily coinsurance for days 1-60 of care
$341 coinsurance per day for days 61-90
$682 coinsurance per “lifetime reserve day” for days 91 and beyond
You qualify for 60 “lifetime reserve days” of hospital care for as long as you have Medicare. Once you use these up, you are responsible for all costs of care.
As an inpatient, you will also pay 20% of the amount Medicare approves for mental health services from physicians and other providers.
Except in severe situations that require emergency room visits, Medicare patients typically access mental health care through their primary care providers or an approved provider of the standard annual depression screening.
However, if you feel that you might need mental health services, you don’t need to wait for your next annual screening. Call your primary care provider and ask about a possible diagnostic visit or referral.
Mental health is a critical part of overall wellness. Always treat mental health symptoms as seriously as you would treat any other signs of illness.