Trying to navigate through Medicare coverage is sometimes a challenge. Most beneficiaries want to know they’re covered if something happens to them, but they might be so focused on learning about physical health benefits that they neglect to consider what will happen if they need mental health care.
The part of Medicare that covers the mental health wellness services you need can change, but many mental health care needs are covered. This includes outpatient, inpatient and medication. The key to coverage is that the services must be medically necessary due to mental illness.
How Are Inpatient Stays for Mental Health Care Services Handled?
Inpatient stays for mental health services are covered by Medicare Part A hospital insurance. Individuals are eligible for up to 190 days of mental health hospitalization in their lifetime. Patients are responsible for covering a deductible when they receive inpatient hospitalization. The deductible varies from one year to another. You also have to pay for your portion of the health professional’s bills that accrue during the stay.
The out-of-pocket costs for the deductible for inpatient mental health care is per stay at the psychiatric hospital, not per year. It resets once you’ve been out of the hospital for at least 60 consecutive days. This means that if you’re discharged and readmitted prior to being out for 60 days, you won’t have a new deductible to pay for the second hospital stay.
You also have to remember that some inpatient stays have a coinsurance payment. These start on day 61 of being hospitalized during a benefit period. It increases on day 91 to either a lifetime reserve day rate or a full patient responsibility rate. You have 60 lifetime reserve days to use over the course of your life. Once those are exhausted, you pay for the full stay starting at day 91.
How Are Outpatient Mental Health Services Covered?
Outpatient mental health care, including diagnostic tests for mental health conditions, one annual depression screening, partial hospitalization, psychiatric evaluations, therapy, medication management, counseling and substance abuse treatment, are covered under Medicare Part B’s mental health coverage. Family counseling, group therapy, group psychotherapy and similar services are also covered. These can be provided by clinical psychologists, clinical social workers, nurse practitioners, physician assistants, nurse specialists and other mental health treatment professionals.
The Medicare Part B covers 80% of the amount Medicare approves for these services, so you’d be responsible for any remaining balance. You also have to ensure that you’re taking care of the Medicare Part B deductible for your plan before Part B covers its portion.
Are Medications Covered Through Mental Health Benefits?
You can review the formulary that’s published by your prescription drug plan provider to determine what medications, including antidepressants, are covered for mental health care. The drugs Medicare pays for are set by Medicare but administered by your Part D medical insurance companies. Many are covered with the standard medication deductible and copayment rates. Some may require that you try other options before you start on them. Your mental health care provider and pharmacy can tell you more about your prescription drug coverage options.
What Else Should You Know?
Medicare covers services from providers who accept the insurance. It’s imperative that you ask any provider you’re working with if they accept Medicare. Any questions should be directed toward your Medicare plan. You can also turn to Medicare.gov or the website for Medicare Advantage Plans.