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Medicare Coverage of Psychological Counseling and Mental Health Services

October  6, 2016

Sometimes it can be hard for older adults to separate signs of mental health problems from aging-related changes. You may think that feeling sad or anxious is a normal part of getting older, especially when you live with challenging health conditions or lose loved ones.

However, if you’re experiencing persistent feelings of sadness or anxiety, social withdrawal, or thoughts of suicide, you should speak with a doctor. Medicare covers many mental health services delivered by providers who accept Medicare assignment and are designed to help diagnose and treat your condition, including preventive screenings, outpatient counseling, hospital inpatient and partial hospitalization services. Generally, you are responsible for paying any applicable deductibles, coinsurance amounts or copayments for covered services.  You are also encouraged to contact your doctor or therapist providing these services to confirm the practitioner accepts Medicare assignment.

Medicare preventive mental health coverage

Medicare Part B helps pay for mental health services you get in an outpatient setting, such as a psychologist’s office or health clinic. This includes preventive benefits to help you stay physically and mentally healthy, such as:

  • Depression screening: All Medicare beneficiaries have coverage for one depression screening every year. You pay nothing for your yearly depression screening if your doctor or health care provider accepts Medicare assignment.
  • ‘Welcome to Medicare’ preventive visit: This one-time initial visit includes, among other things, an assessment of your risk for depression and any factors that may affect your mental health. You must have this visit within the first year you have Medicare Part B to be covered. You pay nothing for this visit if your doctor or other health care provider accepts Medicare assignment.
  • Annual ‘Wellness’ visit: Every year, you’ll be covered for one annual ‘Wellness’ visit, where you can discuss any mental health problems with your doctor, while getting your overall review of your health. You pay nothing for your yearly “Wellness” visit if your doctor or other health care provider accepts Medicare assignment.

If your doctor orders diagnostic tests, a psychiatric evaluation, or refers you for further treatment, you may owe an additional coinsurance or copayment, depending on the service.

Medicare coverage of counseling and outpatient services

Medicare Part B covers counseling and psychotherapy services to treat mental health issues, including group and individual counseling. Medicare covers therapy with a clinical psychologist, psychiatrist, or other health-care professional as long as the provider accepts Medicare assignment. Medicare also covers family counseling when the goal of the therapy is related to your treatment. Medicare doesn’t cover some types of therapy, however, such as marriage counseling or pastoral counseling.

Sometimes mental health conditions can be linked to substance abuse problems, such as drug or alcohol abuse. Medicare covers one alcohol misuse screening per year if you’re not alcohol-dependent. If your doctor determines that you’re abusing alcohol, you can also get up to four counseling sessions to treat your substance abuse problems. You pay nothing for alcohol abuse screening and counseling sessions  if the doctor accepts Medicare assignment.

Medicare Part B covers partial hospitalization programs, which may be another option for those who need more intensive treatment or supervision than that which is available at a therapist’s office, but don’t need to stay overnight at a hospital. These programs may be offered through a mental health facility or hospital and may include diagnostic services and counseling. Partial hospitalization programs don’t cover meals or medical transportation. To qualify for a partial hospitalization program, your doctor must determine that without the program, you’d otherwise need inpatient hospitalization.

Medicare coverage of psychiatric hospitalization

If you need to be hospitalized, Medicare Part A covers mental health services you may need during a hospital or mental health facility stay. Your costs will depend on the length of your stay.  During your hospital stay, Medicare Part B covers physician services provided to you. If you need to stay in a psychiatric hospital rather than a medical facility Medicare Part A covers up to 190 days of inpatient psychiatric hospital care in your lifetime.

Keep in mind that even when you’re hospitalized, Medicare Part B still covers certain mental health services, such as doctor services.

Medicare prescription drug coverage

Your doctor may prescribe medications to treat your mental health condition. If you’re a Medicare beneficiary, you may obtain prescription coverage (Medicare Part D) by enrolling in a stand-alone Medicare Part D Prescription Drug Plan if you have Original Medicare or a Medicare Advantage plan that does not include prescription drug coverage. You can also receive Medicare prescription drug coverage if you enroll in a Medicare Advantage plan that includes Medicare prescription drug coverage, also known as a Medicare Advantage Prescription Drug plan. Stand-alone Medicare Part D Prescription Drug Plans and Medicare Advantage Prescription Drug plans are offered by private insurance companies and contracted with Medicare.

Stand-alone Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans can vary in both costs and which drugs are covered. To find out if a medication you need is covered by a specific Medicare plan that offers prescription drug coverage, check the plan’s drug formulary, which is a list of medications covered by the plan. The formulary may change at any time. You will receive notice from your plan when necessary.

Antidepressants, anticonvulsants, and antipsychotics are considered protected drug classes in Medicare Part D. This means Medicare plans that provide prescription drug coverage must cover nearly all medications in these groups, although there are some exceptions. If your Medicare plan providing prescription drug coverage doesn’t cover a medication that’s medically necessary for you to take, you or your doctor may be able to file an exception to get the medication covered. Your plan may require step therapy, where you first must first try a similar drug.

This article is for informational purposes only. Nothing in it should be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.