Medicare and Mental Health: 4 Key Things to Know

Guest Post by Michael Z. Stahl

October has several days dedicated to recognizing mental health. October 10th is World Mental Health Day and Depression Screening Day, and various worldwide organizations recognize all 31 days of October as Mental Health Month.

But October also marks the start of the annual Medicare Open Enrollment season. Various Medicare plans change annually, so it is important that you have a clear understanding of what is — and is not — covered by Medicare when it comes to mental health care.

Taking care of your mental health is an important part of life. Nearly one in five U.S. adults experience mental illness each year, according to the National Alliance on Mental Illness. The World Health Organization (WHO) estimates that approximately 15 percent of adults over 60 suffer from a mental health disorder.

Mental health care includes services and programs that help diagnose and treat mental health conditions. Whether you are enrolling yourself, a spouse, a parent, or an older relative, keep these four things in mind during the Medicare enrollment process this month:

1. Medicare and inpatient care

Medicare Part A, or hospital insurance, covers inpatient care for mental health, which can be provided in a general hospital or a psychiatric hospital that cares solely for people with mental health conditions. Your plan will cover the costs associated with the hospital room, meals, nursing care, therapy or other treatments, medications, and other related services and supplies. Be aware that Medicare Part A only pays for 190 days of inpatient psychiatric care during your lifetime.

Medicare measures hospital inpatient care by “benefit periods.” A benefit period begins the day you are admitted for inpatient care; it ends once you’ve been released from inpatient care and have gone at least 60 days without skilled nursing care. The amount of coinsurance you’ll pay is based on the length of your stay. There is no limit on the number of benefit periods you can have when care is received in a general hospital. However, with a psychiatric hospital, one can have multiple benefit periods, but only within a 190-day lifetime span.

Medicare Part B will provide some coverage for care and services by doctors or healthcare professionals in an inpatient setting. You would be responsible for paying 20 percent of the Medicare-approved amount for those mental health services while you’re considered a hospital inpatient.

2. Medicare and outpatient care

Medicare Part B covers many mental health services one might seek in an outpatient setting, such as a clinic, doctor’s office, or therapist’s office. The following services and/or visits with healthcare professionals are covered:

• Psychiatrists and other doctors
• Clinical psychologists
• Clinical social workers
• Clinical nurse specialists
• Nurse practitioners
• Physician assistants

Before scheduling the appointment, ask your healthcare provider if they accept assignment. These healthcare professionals must accept an assignment if they participate in Medicare.

Medicare Part B also provides coverage for a variety of outpatient services such as the following:

• an annual depression screening
• diagnostic tests
• group or individual psychotherapy
• psychiatric evaluations 
• lab tests

Counseling is included as a covered service, but it is specific to family counseling that has been solely recommended to help with your treatment. Marriage and relationship counseling would not fall under this category. Medicare Part B does cover certain prescription drugs that are not typically self-administered, such as injections administered in your doctor’s office.

Of course, coinsurance and deductibles still apply. For most cases, once you pay your yearly Medicare Part B deductible, you are then responsible for 20 percent of the Medicare-approved amount if your healthcare provider accepts assignments.

3. Medicare Part D: Prescription drugs

Prescription drugs can be a large component in treating mental health illnesses, conditions, and disorders. If you or a loved one require prescriptions as part of your treatment, you should enroll in a Medicare Prescription Drug Plan to get prescription drug coverage.

Each plan has a list of drugs and prescriptions covered under that plan. While Medicare plans are not required to cover all drugs, they are required to cover antidepressants, antipsychotic and anticonvulsant medications (with minimal exceptions), which may be needed to stay mentally healthy.

If you or a loved one take prescription drugs to treat mental illness, make sure that drug is covered before enrolling in a plan. If your provider thinks you need a certain drug that your plan does not cover, there are processes and appeal resources available.

4. What isn’t covered under original Medicare?

If you are enrolled or shopping for Original Medicare (Part A and Part B), there are some mental health services that are not covered. For example, costs for transportation to and from mental health care services is not provided or covered. Sometimes, for individuals with mental health illnesses or disorders, it’s helpful to find support groups that bring people with similar diagnoses together. However, costs associated with getting to these group settings or any membership fees are not covered. (This is different from psychotherapy.) Additionally, testing or training for job skills that are not related to mental health treatment are also not covered.

A licensed health insurance professional can help you navigate the nuances of Medicare coverage for mental health services. They can ensure you’re getting the best plan that fits all your needs. Mental health treatment is extremely important. So is the coverage that’s available to you or a loved one.

Michael Z. Stahl serves as executive vice president of HealthMarkets—one of the nation’s largest independent health insurance agencies in the Medicare, individual and supplemental health, life, and small group insurance markets. He has a bachelor’s degree in economics from The Wharton School, University of Pennsylvania, and holds the chartered property casualty underwriter (CPCU), associate in insurance accounting and finance (AIAF), and associate in reinsurance (ARe). An avid Kansas City Royals fan, he lives in Dallas with his wife and children.