The Ins and Outs of Mental Health: Costs and Coverage for Different Types of Care

[Note: If you or someone you know is in crisis, call or text 988 or chat at 988lifeline.org (the free and confidential Suicide & Crisis Lifeline). For immediate medical emergencies, call 911.]

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Considering the challenges of the last few years, it is important to remember that your healthcare cannot and should not be separated from your mental well-being.

It's normal to feel low every once in a while. But if this sadness — paired with persistent tiredness or a lack of interest — continues for weeks or months, you might consider seeking mental health care.

In honor of World Mental Health Month, let's talk about the importance of mental health care and how to get coverage.

World Mental Health Day | United Nations

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What Is Mental Health?

Mental health refers to our emotional, psychological, and social well-being.

It affects how we feel, think, and act (i.e., how we cope with stress, relate to others, and make decisions).

Good mental health helps us handle stress and navigate life's challenges. But sometimes, keeping our minds healthy is easier said than done.

That's why we have mental health care!

What is Mental Health Care?

Mental health care involves services used to diagnose, treat, and support mental health conditions.

Examples include:

• Psychotherapy

• Counseling

• Inpatient care

• Support groups

• Prescription medications

When Should I Seek Mental Health Care?

1. You Need Help Managing a Mental Health Condition

You may benefit from mental health care if you have a mental health disorder that affects your mood, thinking, and behavior — such as:

• Depression

• Anxiety

• Schizophrenia

• Eating disorders

• Addictions

Mental health care can help you manage/treat the following symptoms:

• Feeling sad, hopeless, or worthless

• Struggling with sleep

• Feeling confused or disoriented

• Having trouble concentrating or making decisions

• Avoiding social situations

• Having suicidal thoughts

• Feeling unusually tired

• Lacking interest in activities you once enjoyed

• Losing your appetite

• Abusing alcohol or drugs

2. You Need Help Navigating Life Changes

Mental health care is not only for those with diagnosed mental health disorders.

It also helps individuals dealing with life transitions or situational stress, such as:

• A career change

• Moving to a new place

• Feeling isolated during the COVID-19 pandemic

These situations can happen to anybody — regardless of their mental health status. Many people can benefit from receiving help with unfamiliar or stressful situations.

Does Medicare Cover Mental Health Care?

Yes!

Original Medicare helps pay for both outpatient and inpatient services, as well as prescription drugs.

If you have a Medicare Advantage Plan, you may receive additional services not included in Original Medicare. Check your plan details or talk to your service provider about its specific benefits.

What Services Does Original Medicare (Parts A and B) Cover?

1. Inpatient Mental Health Care

Medicare Part A covers inpatient care — in both general and psychiatric hospitals.

It includes the following services:

• Semi-private rooms

• Meals

• General Nursing

• Drugs

• Other hospital services/supplies as part of your inpatient treatment 

However, Medicare doesn't provide coverage for certain inpatient services:

• Private duty nursing

• A phone or television in the room

• Personal items — toothpaste, razors, etc.

• A private room (unless medically necessary)

2. Outpatient Mental Health Care

Medicare Part B covers outpatient visits to:

• Clinics or doctors

• Therapists

• Psychiatrists

• Clinical psychologists

• Clinical social workers

• Clinical nurse specialists

• Nurse practitioners

• Physician Assistants

It also includes the following outpatient services:

• Depression screening once a year

• Individual and group psychotherapy

• Family Counseling

• Testing to find out if you’re getting the services you need

• Psychiatric evaluation

• Medication management

• Administering prescription drugs that can't be self-administered, like injections

• Diagnostic tests

• Partial hospitalization

• A "Welcome to Medicare" visit — a one-time preventive visit within the first 12 months you have Part B

• A yearly “wellness” visit

However, Medicare doesn't cover some outpatient services, such as:

• Meals

• Transportation

• Support groups that bring people together to talk/socialize

  • (This is different from group psychotherapy, which is covered)

• Testing or training for job skills that aren’t part of your mental health treatment

For Medicare to cover your outpatient services, your doctor or healthcare provider must accept the Medicare assignment.

• This is the agreement between a doctor and Medicare regarding fees

• A doctor who accepts an assignment agrees to charge you no more than the amount Medicare has approved for that service 

Does Medicare Cover Prescription Drugs for Mental Health?

Yes. Medicare provides prescription drug coverage if you're enrolled in a plan that covers prescription drugs, such as:

• Medicare Part D

• Medicare Advantage Plan (that includes prescription drugs)

Medicare drug plans generally cover most antidepressant, anticonvulsant, and antipsychotic medications (with a few exceptions).

Each drug plan covers the drugs mentioned in its formulary.

• If your doctor prescribes a medication that your plan's formulary doesn't cover, you can request a coverage determination (including an exception)

• Medicare drug plans may change their formulary throughout the year. If you're already taking a drug that will no longer be covered, your plan will notify you in advance

Know your plan’s coverage rules and rights before enrolling in a drug plan. Compare various drug plans to find out which one covers your medications.

Does Medicare Cover Substance Abuse Services?

Yes. Medicare covers screenings, services, and programs for substance use disorder, including:

1. Alcohol Misuse Screening and Counseling

Adults who use alcohol but do not meet the medical criteria for alcohol dependency can get one free alcohol misuse screening each year.

In addition, you can get up to four brief face-to-face counseling sessions per year if your primary care provider determines you are misusing alcohol.

To get coverage, ensure you get counseling in a primary care setting (like a doctor’s office).

2. Tobacco-Use Counseling and Prevention

If you're having difficulty quitting tobacco, Medicare Part B pays for up to 8 smoking and tobacco-use cessation sessions for one year.

A qualified doctor or Medicare-approved practitioner must provide the services.

3. Opioid-Use Treatment Services

Medicare covers treatment services for opioid use disorder, including:

• Medications

• Substance use counseling

• Individual and group therapy

• Drug testing

• Intake activities

• Periodic assessments

• Opioid antagonist medications

• Overdose education

To qualify, you must sign up for a program with a Medicare-enrolled provider. Talk to your doctor or visit the Medicare website to find the nearest treatment center.

Does Medicare Cover Partial Hospitalization?

Partial hospitalization is a daytime outpatient program that doesn't involve overnight stays.

It's not as involved as inpatient care, but it's more comprehensive than what you'd get in a doctor's or therapist's office.

Medicare may cover partial hospitalization under certain conditions:

• If your doctor certifies that you would otherwise need inpatient care

• If the program is provided through a hospital outpatient department or community mental health center

• If your doctor and the program accept the Medicare assignment

How Much Does Mental Health Care Cost?

Medicare cost depends on the type of mental health service you need and your specific healthcare plan.

Let's dive deeper into the costs for those with Original Medicare:

Cost of Inpatient Services (Medicare Part A)

The exact cost depends on each benefit period.

• A benefit period begins when you're admitted to a general or psychiatric hospital as an inpatient

• It ends the day you leave the hospital or after 60 days

The amount you pay for each benefit period in 2023 are as follows:

• $1,600 deductible

• Days 1–60: $0 coinsurance per day

• Days 61–90: $400 coinsurance per day

• Days 91 and above: $800 coinsurance per each "lifetime reserve day". Lifetime reserve days begin after day 90 for each benefit period (up to a maximum of 60 reserve days over your lifetime)

• Each day after the lifetime reserve days: All costs

Note: If you're in a psychiatric hospital (instead of a general hospital), Part A only covers 190 days of inpatient services during your lifetime.

Cost of Outpatient Services (Medicare Part B)

Medicare covers 80% of the outpatient costs (after you pay the deductible), so you'll pay 20% (or less). Those with Medicare Supplement Plans (Medigap Plans) might pay less than 20% or nothing at all.

However, if you receive your services in a hospital outpatient clinic, you may have to pay an additional copayment or coinsurance.

The exact cost depends on your healthcare plan, whether your doctor accepts Medicare assignments, and which outpatient services you need.

Let's look at some examples:

Costs for Screenings

If your doctor accepts an assignment, Medicare covers 100% of the following services:

• One depression screening per year (free)

• Alcohol misuse screening and counseling (free)

Costs for Opioid Use Disorder Services

Once you pay the deductible, Medicare will cover the rest (as long as your provider accepts Medicare).

Costs for Partial Hospitalization

If your doctor recommends partial hospitalization, you'll have to pay for the following:

• Part B deductible of $226

• A percentage of the Medicare-approved amount for each service

• Coinsurance for each day of partial hospitalization services

Conclusion

Age-related health issues, loneliness, and memory loss can make you feel stressed and challenge your mental well-being. Mental health disorders can come in different forms, and if you're struggling to overcome them, don't hesitate to reach out for care.

Medicare covers both outpatient and inpatient mental health care, as well as any prescription drugs required for treatment.

If you have any questions or concerns, Fair Square Medicare is here to help. Give us a call at 1-888-376-2028.

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