Medicare is a federal healthcare program that provides coverage for millions of Americans aged 65 and older, as well as some individuals with disabilities. Longevity Live Paid Content.
While it offers comprehensive coverage for many medical services, there is often confusion surrounding its coverage of mental health services. In this article, we will explore the extent to which basic Medicare covers mental health, including the types of services covered, limitations, and options for additional coverage.
Basic Medicare consists of four main parts: Part A, Part B, Part C, and Part D.
Part A typically covers inpatient hospital stays, noncustodial nursing home care, skilled nursing facility care, home health care, and hospice care. At the same time, Part B covers outpatient services, such as preventive services, doctor visits, lab work, durable medical equipment, and more.
Part C refers to Medicare Advantage plans, while Part D covers prescription medications. Lastly, there are Medicare Supplement plans, also known as Medigap plans. These plans help cover cost-sharing with Part A and Part B. The supplement plan someone may choose depends on different factors.
Coverage for Mental Health Services
Medicare does provide coverage for certain mental health services under both Part A and Part B. However, it’s essential to understand the limitations and conditions associated with this coverage.
Inpatient Mental Health Services
Under Part A, Medicare covers inpatient mental health care in a psychiatric hospital or general hospital. This includes services such as room and board, nursing care, certain drugs, and general hospital services and supplies.
Something else to note is that Part A operates using benefit periods. A benefit period begins the day someone is admitted as an inpatient. The period ends once that person has not had inpatient care for 60 consecutive days. If that person were to be admitted again as an inpatient after those 60 days, a new benefit period would begin, starting the cycle over again.
There is no limit to the amount of benefit periods someone can have. However, Part A only covers up to 190 days of inpatient hospital care during a beneficiary’s lifetime, with a lifetime reserve of an additional 60 days.
Outpatient Mental Health Services
Medicare Part B helps cover mental health services administered by a wide range of mental health professionals, including psychiatrists, clinical psychologists, nurse practitioners, and more, whether outside of a hospital or inside a hospital’s outpatient department.
Some covered services include doctor’s office visits, individual and group counseling sessions, depression screenings, psychiatric evaluation, diagnostic testing, certain medications, and more.
However, it is important to know that Part B will likely not cover these services if the provider does not accept Medicare assignment. Medicare assignment is an agreement between Medicare and a provider where the provider agrees not to charge more than the Medicare-approved cost for a given service.
Medicare Mental Health Limitations and Cost-Sharing
While Medicare covers many mental health services, there are limitations and cost-sharing requirements that beneficiaries should be aware of.
Part A Mental Health Limitations and Costs
Medicare beneficiaries are responsible for paying the Part A deductible for each benefit period for inpatient mental health care as well as coinsurance costs based on how many days they’ve been receiving inpatient care.
For example, during a benefit period in 2024, days 61 through 90 of an inpatient stay cost $408 each day.
Part B Mental Health Limitations and Costs
For outpatient mental health services, Part B covers 80% of approved services after the Medicare beneficiary has met their annual Part B deductible. The leftover 20% falls to the beneficiary, typically in the form of a coinsurance or copayment.
Coverage Gaps and Additional Options
Despite Medicare’s coverage of mental health services, gaps remain that may leave beneficiaries with out-of-pocket expenses. Fortunately, options exist to help cover these gaps.
Individuals may consider additional coverage, either a Medigap or a Medicare Advantage plan, to address these cost-sharing expenses.
Medicare Supplement Plans (Medigap)
While Medigap plans do not cover mental health services directly, they can help with out-of-pocket costs including deductibles, copayments, and coinsurance associated with Part A and Part B. Medigap plans are secondary to Medicare, so Medicare will pay first for approved services and Medigap plan will pay second.
There are ten different Medigap plans available, all with varying levels of coverage. The top two most popular Medigap plans currently are Plan G and Plan N. These two plans are favored the most because they offer a great deal of coverage for Part A and Part B cost-sharing.
For example, if someone has Medicare and Plan G, they will have no out-of-pocket costs for Medicare-approved services once they meet the annual Part B deductible.
Medicare Advantage Plans (Part C)
Medicare Advantage plans are another option for people to consider. Unlike Medicare, private insurance carriers offer advantage plans. This means that people who enroll in an Advantage plan receive all their medical care through that plan. Instead of Medicare Part A and Part B.
Cost-sharing with Advantage plans works differently than Medicare Part A and Part B. These plans decide what they will charge for approved services, including monthly premiums, deductibles, copayments, and coinsurance.
The costs they set can be more cost-effective for some people than the costs with Medicare. However, beneficiaries should check each Advantage plan carefully, as the costs will vary from plan to plan.
These private insurance plans can also offer additional benefits beyond original Medicare, including coverage for mental health services. Many Medicare Advantage plans include prescription drug coverage and may offer more extensive coverage for mental health medications.
Medicare Prescription Drug Plans (Part D)
Medicare Part D plans provide coverage for prescription medications, including antidepressants, antipsychotics, anticonvulsants, and more. Beneficiaries can choose a Part D plan that covers their specific medications.
However, each Part D plan has a different list of covered medications called a drug formulary. Medicare beneficiaries should check each plan’s formulary to see if their medications are covered before enrolling in a particular plan.
Summary
In conclusion, basic Medicare does provide coverage for mental health services, including both inpatient and outpatient care. However, beneficiaries should be aware of the limitations, cost-sharing requirements, and coverage gaps associated with Medicare’s mental health coverage.
Exploring additional coverage options, such as Medicare Advantage plans, Part D prescription drug plans, or Medigap policies, can help individuals ensure comprehensive coverage for their mental health needs. Beneficiaries should review their options carefully and choose the plan that best meets their unique healthcare needs and budget.
