What Kinds of Mental Health Care Do Medicare and Medigap Cover?
Millions of Americans deal with mental illness every year. Although Medicare and Medigap cover some related treatments and drugs, they don't cover all of them.
This year, somewhere around 58 million Americans will receive Medicare benefits. About one in five adults in the U.S. deals with a mental illness in any given year. It's fair to say many Medicare enrollees need mental health services.
The question is: does Medicare cover mental health services like therapy sessions, other treatments, and even drugs? And if so, how much does it cover?
Keep reading to learn all about Medicare, mental illness, and more. We’ll also discuss how Medigap works with mental health.
Before we get to Medicare and mental health care, let's go over the basics of this decades-old, single-payer program.
The U.S. government began administering Medicare in 1965. Medicare provides health insurance to Americans who are at least 65 years old and have paid into the system via a payroll tax.
It also covers younger people who have certain disabilities. And it covers those with end-stage renal disease as well as those with Amyotrophic Lateral Sclerosis (ALS), too.
In addition, Americans can get Medicare coverage in two ways. One way is to sign up for Original Medicare, which is made up of "Part A" and "Part B." Many call Part A "hospital insurance" and Part B "medical insurance." Another way is to go with a Medicare Advantage plan--otherwise known as "Part C."
Some people choose a Medicare Advantage plan rather than Original Medicare because they'd rather receive their benefits through a private health plan such as a Preferred Provider Organization (PPO) or a Health Maintenance Organization (HMO).
Original Medicare and Medicare Advantage plans cover the same services, but the latter can be cheaper. Plus, most offer additional benefits like Medicare Part D coverage.
Speaking of Medicare Part D, it provides prescription drug coverage. Insurers and other private companies approved by Medicare administer these plans, which vary in cost and in which drugs they cover. For more information, see our Medicare Part D article.
Another way Americans can add to their health coverage is through Medicare supplement insurance, often referred to as MedSup or Medigap.
Learn more about Medicare in this ultimate guide. Also, read up on the differences between Medigap and Medicare Advantage plans.
The Basics of Medicare and Mental Health Care Coverage
With that out of the way, here's what you need to know about how Medicare does and doesn't cover mental health care.
According to medicare.gov, Medicare Part A helps pay for the following during inpatient hospital stays:
- You room
- Therapy or other treatment of your condition
- Lab tests
- Nursing care
- Other related services and supplies
Medicare Part B, on the other hand, helps pay for mental health services provided outside of a hospital. A few examples:
- Psychiatrist or other physician appointments
- Clinical psychologist or clinical social worker visits
- Doctor-ordered lab tests
Something else Part B covers: partial hospitalization for people who require coordinated outpatient care.
Finally, Medicare Part D covers prescription drugs needed to treat a mental illness or mental health condition.
More About Medicare Part A and Mental Health Coverage
As mentioned earlier, Medicare Part A helps pay for mental health treatment you receive while in a hospital. Specifically, you must be admitted as an inpatient for Part A to pick up part of these costs.
Medicare won't only help out if you're a patient at a general hospital, by the way. It'll also help out if you're admitted to a psychiatric hospital.
That said, Medicare only covers a certain amount of inpatient care at psychiatric hospitals. Specifically, it only pays for 190 days of this kind of care during your lifetime.
Medicare uses "benefit periods" when calculating hospital coverage. A benefit period starts when you're admitted to a hospital as an inpatient. It ends when 60 days in a row have passed since you last received inpatient care.
Medicare doesn't limit the number of benefit periods an enrollee can use while receiving mental health care in a hospital.
More About Medicare Part B and Mental Health Coverage
As for Medicare Part B, it helps cover the costs tied of mental health treatment outside of a hospital. It pays for care that takes place in a clinic, a community mental health center, or in a doctor’s or therapist’s office.
It also pays for care provided by a hospital’s outpatient department.
Here are a number of specific outpatient services Medicare covers:
- Annual depression screenings
- Psychiatric evaluations
- Individual and group psychotherapy
- Family counseling
- Medication management
- Prescription drugs you can't or usually don't take on your own (such as injections)
- Diagnostic tests
- Partial hospitalizations
For more information on which outpatient services Medicare covers and which ones it doesn't, visit medicare.gov.
Keep in mind you may have to pay deductibles or coinsurance for this kind of outpatient care.
Also, Medicare only covers care provided by physicians and practitioners who accept assignment. To accept assignment, a provider has to agree to be paid directly by Medicare. They've also got to accept the amount Medicare approves for the treatment in question. And they can't bill patients for more than the Medicare coinsurance and deductible.
You should always make sure your provider accepts assignment before you make an appointment with them.
More About Medicare Part D and Mental Health Coverage
As mentioned earlier, Part D covers prescription drugs. In this case, it covers drugs that treat a mental illness.
Unfortunately, Part D doesn't cover all such drugs. It does cover nearly all anticonvulsant, antidepressant, and antipsychotic medications, however.
Of course, there are exceptions. Before you enroll in a Part D plan, make sure it covers whatever drugs you take for your condition.
Note: you can do this quickly and easily at medicare.gov/find-a-plan.
Medigap, MedSup, and Mental Health Care
For starters, both Medigap and MedSup are terms for a product normally called Medicare supplement insurance.
As implied, this policy supplements the costs related to Original Medicare. To put it another way, it helps people pay for some of the expenses Medicare doesn't cover.
Learn more about this type of plan in our "Medicare Supplement Insurance Policy FAQ."
That's true whether you're talking about general health care or mental health care. For example, most Medigap plans cover the costs Medicare Parts A and B won't pay for if you're hospitalized for mental illness.
A few examples:
- All Medigap policies cover your Part A hospitalization copays and coinsurance
- They also cover all or part of your psychiatrist’s copays and coinsurance
- Most of these plans cover your Part A hospitalization deductible, too
MedSup and Medigap plans help if you're ever get outpatient treatment for mental illness as well. Specifically, they usually cover some or all of your Part B out-of-pocket costs.
Frequently Asked Questions
Q: Which types of mental health care, treatments, and services doesn't Medicare cover?
A: Good news! The list of things Medicare doesn’t cover is a lot shorter than the list of things it does cover.
Here, for example, are the items Part A doesn't cover:
- A private room, unless one is necessary
- A phone or television in your room
- Personal items like a toothbrush or a razor
- Private duty nursing
And here are the items Part B doesn't cover if you're partially hospitalized:
- Any and all meals
- Support groups
- Job-skill testing or training not tied to your mental health treatment
Q: What kinds of health care professionals can I see as a Medicare enrollee?
A: Medicare Part B will pay for at least a portion of the care you receive from the following:
- Psychiatrists or other physicians
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Clinical psychologists
- Clinical social workers
Q: What if my physician or psychiatrist doesn't accept Medicare?
A: If your doctor or other specialist doesn't accept Medicare, you'll have to pay the total bill for your treatment.
Because of this, make sure you ask if he or she has opted out of Medicare before making an appointment.
Thankfully, physicians who don't accept Medicare have to ask you to sign a contract that makes this clear.
Still, it's always better to be safe than sorry, so always ask if no one else brings it up.
And to be sure, check medicare.gov/physiciancompare/. It directs you to providers in your area who accept Medicare payment.
Q: What if my doctor or specialist recommends a mental health service or treatment that Medicare doesn't cover?
A: Unfortunately, you'll probably have to pay for some or all of that service or treatment.
The same is true, by the way, if you have a test, treatment, or service done more often than Medicare allows.
In cases like these, talk to your doctor or other specialist about why he or she thinks you should do them so frequently. And then use that information to decide if you should agree to it or not.
Q: What if I need a drug my Medicare Part D plan doesn’t cover?
A: According to medicare.gov, if you have a Medicare drug plan, you can ask for a coverage exception.
Basically, this means you can ask your plan to provide or pay for a drug you think should be covered.
You also can appeal your plan's decision about whether or not to provide or pay for a drug.
Before you take either of these steps, though, talk with your doctor or the health care provider who wrote the prescription. He or she should be able to tell you if your plan has special coverage rules. They also can tell you if any generic or over-the-counter drugs could work as well as the ones they prescribed.
If that doesn't help, go to cms.gov for more on how to request a coverage determination or exception.
Q: How can I find out how much I'll have to pay for a mental health treatment after Medicare covers its portion?
A: Talk to your doctor or health care provider before you agree to any test or treatment. They can walk you through the costs of any treatment.
Also, know that how much you pay depends on several variables, including:
- where your test or treatment is done
- the price your physician or provider charges for the test or treatment
- any other insurance you have
Q: Will Medicare continue to cover mental health care if President Trump and Congress make cuts to the program?
A: This is a difficult question to answer. While on the campaign trail, President Trump promised to leave Medicare intact. So far, he has kept that promise. Still, the 2018 budget plan House Republicans put forth this summer proposed cuts to the program. That doesn't mean future Medicare cuts are a certainty, of course, but they're definitely a possibility.
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