How Exactly Does Medicare Cover Mental Health
By Danielle Roberts
Turning 65 and approaching Medicare age can be a scary time. Most people have had their insurance choices selected for them for years by their employers. Having to learn the ins and outs of a national health insurance program is a whole new ball game.
Fortunately, Medicare has pretty comprehensive coverage for both inpatient and outpatient services. This includes care for regular medical services as well as mental health care.
It’s not unusual for adults age 60+ to need help with mental health care. It is estimated that over 7 million people over 65 will experience a mental health disorder, and this includes things like depression, which is quite common as people get older.
Should you need help, it’s good to know that Medicare provides decent benefits.
Prevention, Counseling and Psychiatric Care
Most mental health care will fall under Part B of Medicare, which is your outpatient coverage. After a small deductible, Medicare Part B will pay for 80% of your services. On the medical side, Part B covers doctor’s visits, lab-work, medical equipment, surgeries and more.
For mental health care, Part B covers normal services that you would use on an outpatient basis, such as individual or group counseling, visits with a psychiatrist or clinical psychologist. It also covers an annual depression screening which can be performed at no charge by your primary care doctor.
Sometimes people need more structure care, and this is covered under Medicare Part B’s partial hospitalization benefits. If your doctor certifies your need for this care, then this benefit provides for you to receive more formal care in a hospital outpatient clinic or community mental health facility.
Any drugs provided to you in a clinical setting will fall under Part B as well. Outpatient drugs are covered differently, which we’ll discuss further below.
Since Part B only covers 80% of your outpatient services, many individuals enroll in a Medigap plan to help pay the other 20%. Medigap plans are standardized and regulated by the federal government, but they are sold by private insurance companies. Most states have 10 plans that you can choose from, according to how much coverage you wish to have. Plan F is currently the most comprehensive coverage.
Inpatient Care
Medicare also provides for some inpatient mental health care. Under Part A, you can receive up to 190 lifetime days of inpatient mental health care in a psychiatric facility. Think of Part A as what covers your room rental. It will pay the bill for the hospital stay itself, your care by nurses while in the hospital, and any skilled nursing care you may receive.
Medicare measures your inpatient hospital care in benefit periods. When you are admitted to a hospital, a benefit period begins. You owe a deductible, which in 2018 is $1340. This covers the first 60 days in the hospital. Should your stay extend longer, you begin paying a daily copay on day 61.
This copay increases with time and benefits run out after 150 days. However, if you leave the facility and are out for more than 60 days, then you can re-enter and begin a new benefit period.
Outpatient Drug Coverage under Medicare
Any medications that you fill at a local pharmacy will fall under Part D. You join a Part D drug plan by applying directly with the insurance company or through one of its agents. There is often a dozen or more plans offered in each state.
Each plan has a drug formulary, so it’s important that you check the formulary before you enroll to make sure that your needed medications are covered by the plan. Fortunately, there are some basic minimum guidelines for all drug plans, and one of those guidelines is that all drug plans must carry antidepressants and antipsychotics. In fact, the plans must cover at least two medications in every therapeutic class.
When you go to the pharmacy, you’ll present your Part D insurance card. The pharmacist will bill the drug plan and you are only responsible for the copay that is designated in the plan’s summary of benefits. In most cases, the insurance company pays the larger share of the cByost of the medication.
Part D drug plans also all have catastrophic coverage limits. If you have expensive medications which require a lot of out of pocket costs, you are protected by this cap. Once you reach it, you only owe 5% of the cost of your medications for the rest of the year.
Summary
It’s understandable to worry about your mental health coverage when you are enrolling in new health insurance. Fortunately, the various parts of Medicare do include benefits for mental health just as they do for medical health. If you think you may need care, consult your doctor for more information on your options.
Danielle K Roberts is the co-founder of Boomer Benefits, an agency that helps Baby Boomers navigate their entry into Medicare.
The views and opinions expressed in this post are those of the author and do not necessarily reflect all or some of our beliefs and policy. Any links on this page does not necessarily mean they have been endorsed by Defying Mental Illness.
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