Mental health and well-being is an important aspect of overall health. Whether you are enrolling or are currently enrolled in Medicare, you should have a good understanding of what mental health services are covered by Medicare. Before going into what mental health services are typically covered, let's go through a brief overview of what Medicare is.
Medicare is the federal health care system for individuals aged 65 and over. Every year, there are specific dates to enroll for both parts of Original Medicare and Medicare Advantage plans. The basic aim of these programs is to help seniors pay for medical services, including hospital and medical care.
Medicare is split into four parts: A, B, C, and D. Each of these parts covers a different category of health care insurance.
Part A: Covers hospital insurance (in-patient care)
Part B: Medical Insurance (out-patient care)
Parts A and B make up Original Medicare
Part C: Medicare Advantage Plan
Part D: Prescription Drug Coverage
Part B of your Original Medicare Plan covers some mental health services under out-patient and in-patient care; however, Medicare Advantage plans cover additional mental health care services.
Read more about What Types of Medicare Are There?
Understanding what is and is not covered by Medicare will give you a better foundation for choosing mental health care coverage.
The Medicare Advantage Plan includes Original Medicare benefits with the addition of other services, such as dental, vision, hearing, and mental health care. This part of Medicare is privatized, so you’ll have to choose a private insurance company to start your Medicare Advantage Plan. If your mental health services require prescription drugs, then you should also look into Part D of Medicare; that is the Prescription Drug Coverage Plan. Part D is an add-on to Medicare Advantage plans.
To determine whether you need mental health care services, Medicare.gov states that you should “talk to your doctor if you’re experiencing the following symptoms:
Thoughts of ending your life
Sad, empty, or hopeless feelings
A lack of energy
Little interest in things you used to enjoy
Weight loss or loss of appetite
Increased use of alcohol or other drugs
Loss of self-worth
Social withdrawal and isolation”
In Medicare, the policies include a term referred to as "fee-for-services." These are usually related to mental health services or any service that requires you to pay for the mental health care received, such as an hourly psychotherapy treatment.
If you have a Medicare Advantage Plan, then you already have Parts A and B, which cover inpatient and outpatient services. These are useful for stays at a “general or psychiatric hospital.”
Some covered items are: depression screening (once per year), alcohol misuse screening (once per year), opioid use disorder treatment, and others (discussed later in this article).
Medicare mental health care, also referred to as "behavioral health and wellness" or "behavioral health services," includes a wide range of services, from psychotherapy to treatment for addictions. Not every provider is fully covered under the mental health care policies, though. We’ll go over each provider covered and what you’re allowed in the coverage, including what percentage of the services Medicare covers.
Most professional services are covered between 75% to 100%, and all professionals must have the required qualifications for their position. Many of them need a license or certification from the state that they are practicing in. Make sure to look out for these factors when choosing a health care practitioner.
When you choose a psychiatrist for mental health treatments, they must have MD or DO qualifications. All psychiatrist sessions are fully covered under the Medicare Physician Fee Schedule (PFS).
The clinical psychologist you select for mental health treatments must have a Doctorate in Psychology and a license/certification from the state where they practice. All CP treatments are fully covered under the Medicare Physician Fee Schedule. However, these are paid for on an assignment basis, meaning that Medicare has pre-approved an amount that is not an hourly rate. This amount is determined on a case-by-case basis.
Your clinical social worker must have a Master of Social Work or doctoral degree, and they must have had clinical supervision for at least two years. CSWs must also hold a license in the state where they practice. All services from CSWs are covered 75% under Medicare PFS, on an assignment basis.
The clinical nurse specialist must be a registered nurse and have a license in the state where their practice is located. Care by all CNSs is covered 85% under Medicare PFS, on an assignment basis.
Your nurse practitioner must have the same qualifications as the above CNS. Medicare pays for 85% of the mental care services they perform.
The coverage is 85% of Medicare PFS treatments, on an assignment basis. According to Medicare Mental Health, “Medicare pays your employer or contractor for assistant-at-surgery services at 85% of the amount a physician gets under Medicare PFS.” The PA must have graduated from a PA educational program and have passed a national certification exam.
Medicare Mental Health states that CNM services are covered "at 80% of the lesser of the actual charge or 100% of the amount the physician gets under Medicare PFS.” This is also on an assignment basis. The CNM must be a registered nurse who is authorized to work as a CNM in the state where the services are provided.
Sessions with IPPs are fully covered by Medicare, including any psychological and neuropsychological tests they perform. This professional must be a psychologist who is not also a CP.
Part of the January 2020 update to Medicare Mental Health Care was the addition of coverage for Opioid Treatment Programs (OTPs). If you have Medicare Part B, or a bundled Medicare Advantage Plan, then your insurance covers FDA-approved opioid services. These services, according to Medicare Mental Health, are the following:
"FDA-approved opioid agonist and antagonist medication
Assisted treatment + Administration of medication
Individual and group therapy
Medicare offers services for individuals who misuse alcohol but do not have a dependency on it. Patients receive free screening and counseling; however, only four face-to-face sessions are allowed per year. Individuals must also be fully alert during these sessions for the coverage to qualify.
There are also treatments for alcohol addiction for those who are dependent on it. Medicare offers alcohol treatment and detoxification. Services include all outpatient hospital treatments, rehabilitation services, and hospital stays.
Medicare mental health coverage includes an abundance of fee-for-service treatments, but there are some services that are not covered by Medicare and will require an out-of-pocket payment, or that you invest in a separate insurance policy.
According to the official Medicare Mental Health Services Guide, the following fee-for-services are not covered:
"Environmental intervention or modifications
Adult day health programs
Biofeedback training (any modality)
Results or data interpretation or explanation
Hemodialysis specifically for treating schizophrenia (experimental)
Transportation or outpatient meals
Phone services, or apps"
It’s important to note that Medicare Part D is specifically for prescription drugs and that many of these drugs are not covered in Original Medicare (Parts A and B). You may want to look into prescription drug coverage plans if the mental health services you require will involve drugs that aren’t covered by Parts A and B.
The Medicare Advantage Plans cover additional mental health care that is not already covered by Medicare Part B (outpatient care). If you would like a more diverse coverage for mental health, looking into Advantage plans will be helpful.
Medicare covers a wide range of mental health care treatments. If you have Original Medicare, Parts A and B, then you already have access to professional help if you need it. However, a Medicare Advantage Plan will ensure you have more versatile coverage than an Original Medicare plan by itself can provide.
Mental health is just as important as physical health. When we have physical pain, we rush to see a doctor, but when we have mental health issues, it can be harder to seek help due to the stigma attached.
Your mental health is an essential factor in the quality of your life, and you deserve to get the help you need. You may also have access to online assistance. If you are interested in learning more about telehealth treatments, visit us here.