How Medicare covers mental health

by Greg Dill, Medicare regional administrator for Arizona, California, Nevada, Hawaii, and the Pacific Territories

Let’s hope it never happens, but there may come a time in your life when you need mental health care. Your Medicare covers a wide variety of such services, in both hospital inpatient and outpatient settings.

If you have Medicare Part A (hospital insurance), you’re eligible for mental health services when you’re admitted to a hospital as an inpatient. You can get these services either in a general hospital or a psychiatric hospital that only cares for people with mental health conditions.

If you're in a psychiatric hospital (instead of a general hospital), Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime.

Medicare pays for inpatient hospital stays on the basis of “benefit periods.” A benefit period begins the day you’re admitted to a hospital as an inpatient. It ends when you haven’t received any inpatient care for 60 days in a row.

If you go into a hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible ($1,340 in 2018) for each benefit period.

There’s no limit to the number of benefit periods you can have. But remember, there’s a lifetime limit of 190 days for inpatient psychiatric hospitals.

After you pay the deductible, Medicare covers inpatient hospital care for the first 60 days with no coinsurance on your part for each benefit period.

For days 61-90, your coinsurance is $335 per day of each benefit period.

If you’re in the hospital beyond 90 days, your coinsurance is $670 per "lifetime reserve day" for each benefit period (you have up to 60 reserve days over your lifetime).

In addition, you’ll pay 20 percent of the Medicare-approved amount for mental health services you get from doctors and other providers while you're a hospital inpatient.

Your Medicare Part B (medical insurance) covers partial hospitalization in some cases.

Partial hospitalization provides a structured program of outpatient psychiatric services as an alternative to inpatient psychiatric care. It’s more intense than care you get in a doctor’s or therapist’s office. This treatment is provided during the day and doesn’t require an overnight stay.

Medicare helps cover partial hospitalization services when they’re provided through a hospital outpatient department or community mental health center. Along with partial hospitalization, Medicare may cover occupational therapy that’s part of your mental health treatment and/or individual patient training and education about your condition. 

Medicare only covers partial hospitalization if the doctor and the partial hospitalization program accept Medicare as full payment.

For Part B to cover a partial hospitalization program, you must meet certain requirements, and your doctor must certify that you would otherwise need inpatient treatment.

Under Part B, you pay a percentage of the Medicare-approved amount for each service you get from a doctor or other qualified mental health professional if they accept Medicare rates.

You also pay coinsurance for each day of partial hospitalization services provided in a hospital outpatient setting or community mental health center. The Part B deductible ($183 in 2018) applies as well.

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

All of the above applies to people with Original Medicare. If you’re in a Medicare Advantage (Part C) health plan, check with the plan for details of how it covers mental health care.

For more information on your Medicare mental health benefits, I recommend this detailed brochure: https://www.medicare.gov/Pubs/pdf/10184-Medicare-Mental-Health-Bene.pdf.

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Greg Dill is Medicare’s regional administrator for Arizona, California, Nevada, Hawaii, and the Pacific Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).