If you’re over 65 years old, there is a 1 in 4 chance you are navigating a mental health condition, according to the
National Council on Aging, and an even higher chance you’re enrolled in Medicare. While mental health care is necessary, understanding if Medicare covers mental health treatment can be complex.
Read on to learn more about which mental health services Medicare covers, important terminology and how to find Medicare mental health care near you.
Medicare Coverage for Inpatient Mental Health Treatment
Medicare Part A (hospital insurance) provides some coverage for your mental health hospital stay. Part A coverage of mental health admissions is similar to other types of inpatient hospital stays.
| Inpatient stay duration | What you pay | Notes |
| Days 1-60 | $1,632 deductible | There’s a one-time deductible for each benefit period. The benefit period starts when you are admitted and ends once you have been discharged for 60 consecutive days. This amount, and the ones below, may change for 2025. |
| Days 61-90 | $408 per day | This applies after day 60 in the same benefit period. |
| Days 91 and beyond | $816 per day | After day 90, you tap into your total lifetime reserve days for additional coverage. You have a total of 60 lifetime reserve days. |
| After lifetime reserve days are used | All costs | After you exhaust all 60 of your reserve days, you pay all costs associated with your inpatient care. |
| Mental health services while you are inpatient | 20% of the Medicare-approved amount | This applies to all outpatient-type services you receive while inpatient, such as group therapy. |
Although there is no limit to benefit periods you can have, once you run out of lifetime reserve days, they’re gone forever. However, Medicare Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime. That being said, if you are admitted to a general hospital, and get treatment for mental health, those days are counted separately.
Medicare Part B (medical insurance) is also involved with some of your inpatient stay coverage. It covers some of the services offered while you’re admitted for inpatient mental health treatment, such as:
— Visits from your psychiatrist to check on your progress
— Consultations between providers, such as a psychiatrist and a pharmacist discussing how two of your mental health medications may interact
— Counseling or therapy you receive while inpatient
[READ The Parts of Medicare Explained: What They Cover and What They Don’t]
Medicare Coverage for Outpatient Mental Health Treatment
Medicare Part B also covers some outpatient mental health services, such as:
— Individual or group therapy, including marriage and family therapy if it relates to your mental health condition
— Diagnostic tests, such as cognitive testing or behavioral assessments
— Medication management services, such as a psychiatrist evaluation of an anxiety medication‘s effectiveness
— Preventive services, such as depression screenings or alcohol misuse screenings
— Substance use treatment programs, such as smoking cessation programs or opioid use disorder counseling
— Partial hospitalization programs or intensive outpatient programs
Up until this year, Medicare has not reimbursed licensed counselors for their services. Now that they are, this could help with the mental health care shortage and allow more people to be seen, says Jessica Topolski, a Medicare specialist at AZ Health Insurance Brokers in Phoenix.
Outpatient mental health treatment may be provided in any of the following settings:
— Doctors’ offices
— Community mental health centers
— A hospital’s outpatient mental health department, such as intensive outpatient programs for mental health treatment
| Outpatient service coverage | What you pay | Notes |
| Preventive care | $0 | There’s no cost if your provider accepts Medicare. |
| Visits to diagnose or treat mental health conditions | 20% of the Medicare-approved amount after you meet the Part B deductible of $240 in 2024 (this deductible amount could change in 2025) | For example, the Medicare-approved amount for 45 minutes of psychotherapy is around $100, depending on location. You would owe $20 after meeting your deductible. |
| Services in hospital outpatient clinic or department | 20% of the Medicare-approved amount, as well as possible copayments and coinsurance | Additional fees may apply for hospital-based services. |
[Read: Low-Cost Therapy Options for Every Budget.]
Medicare Prescription Drug Coverage for Mental Health
Medicare Part D (drug coverage) contracts with private insurance companies to negotiate the price of drugs. Drug coverage with Medicare Part D varies depending on the drug, because medications are sorted into cost tiers. Part D covers some prescription drugs for mental health.
Some medications covered by Part D include:
— Stimulants, such as Adderall for ADHD treatment
— Antipsychotics, which are medications used to treat conditions such as bipolar disorder or schizophrenia
Here are some tips to ensure maximum coverage:
— Take a formulary drug, if possible. Formulary drugs are a list of specific prescription drugs covered under your Medicare Part D plan. For example, you may save money if you take the generic sertraline for depression versus the brand name Zoloft.
— Check for prior authorizations. Medicare might require you to submit paperwork, such as a visit to the doctor, mental health assessments and diagnosis codes, to receive coverage approval for your prescription.
— Ask your doctor about step therapy. Sometimes Medicare asks that you try — and fail — a less expensive drug before granting coverage for a more expensive drug.
Medicare Part D coverage is sorted into coverage phases. As you progress through these phases, the amount you pay for your medications changes based on your total drug spending.
| Prescription drug coverage phase | What you pay | Notes |
| Deductible phase | A maximum of $545 in 2024 (this amount could change in 2025) | At the beginning of your benefit year, which begins January 1 and ends December 31, you will need to meet your deductible before Medicare Part D kicks in. |
| Initial coverage phase | Variable copayments or coinsurance based on the drug tier (tiers 1-3 or specialty tier), up to the initial coverage limit | After you meet your deductible, you pay a copayment or coinsurance for each prescription, and Medicare Part D covers the rest. This continues until you meet the initial coverage limit of $5,030 in 2024. |
| Coverage gap (“donut hole”) | Up to 25% of drug costs | If your out-of-pocket spending exceeds the initial coverage limit, you’ll pay up to 25% of drug costs until you reach the out-of-pocket max of $8,000 in 2024. |
| Catastrophic coverage | Variable copayments or coinsurance based on the drug tier | Once your out-of-pocket spending reaches a certain level, your costs for covered drugs drop and you pay a copayment or a percentage of the drug cost. |
Starting in 2025, all Medicare plans will have a lowered $2,000 out-of-pocket maximum for prescription drugs, shrinking the donut hole.
“Annual true out-of-pocket costs decreasing significantly will help reduce the costs of mental health medications,” Topolski says.
[READ: How Can I Find the Best Psychiatrist?]
Challenges With Medicare Mental Health Coverage
Medicare does provide mental health coverage, but there are some key issues to be aware of.
— Coverage limitations. One of the biggest setbacks of Medicare coverage for mental health is the limitations on coverage, says Kristie Tse, a New York City-based psychotherapist and founder of Uncover Mental Health Counseling, an online therapy platform. “The requirement of a diagnosed mental disorder to qualify for benefits can exclude some individuals who are experiencing distress, but lack a formal diagnosis,” she explains.
— Lack of providers who accept Medicare. “Medicare has improved what they cover for mental health, but it’s not a perfect system,” Topolski says. “A lot of mental health providers do not take Medicare, and we have a shortage of psychiatrists across the country. They use a cash-based system instead of having to deal with billing Medicare.”
— Difficulty when dually enrolled in Medicare and Medicaid. “Individuals becoming dually eligible for Medicare and full Medicaid benefits in the past have not had access to certain behavioral health services or providers they previously had access to through Medicaid,” says Sarah Barth, New York-based executive director of marketing at Altarum Medicare Medicaid Services for States, a nonprofit organization that helps states create financially sustainable solutions to advance health. “This is due to complex rules requiring Medicare to cover services before Medicaid for people eligible for both programs.”
Although there are challenges with Medicare mental health coverage, Medicare does offer significant help for seniors who need mental health care and access.
Explore Top-Rated Mental Health Professionals With U.S. News & World Report
By understanding the mental health resources available to you, you can ensure that you get the mental health care you need. Don’t miss the opportunity to enroll in Medicare or shop for a Medicare Advantage plan. The annual Medicare open enrollment period runs from October 15 to December 7.
To connect with mental health providers, look at U.S. News and World Report’s suggestions for psychiatrists near you.
If you’re looking to compare psychiatric hospitals, check out the U.S. News and World Report’s list of top psychiatric hospitals. The seven mental health hospitals ranked in psychiatry or psychiatric care were recommended by at least 5% of the psychiatric specialists responding to U.S. News surveys in 2022, 2023 and 2024. An additional 26 hospitals were recommended by at least 1% of the respondents.
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Does Medicare Cover Mental Health Treatment? originally appeared on usnews.com
