One in five Americans suffers from mental illness in any given year. This not only affects their health and quality of life, but it also costs them millions of dollars every year in lost productivity and out of pocket expenses. Part of the problem is access to care. Only 45% of people with mental health issues got treatment for those conditions in 2019. Whether someone is on Original Medicare or a commercial Medicare Advantage plan, the Centers for Medicare & Medicaid Services (CMS) has a responsibility to provide adequate access and affordable coverage for its more than 67.7 million beneficiaries.

How Medicare Covers Mental Health

Regardless of the mental health condition, Medicare covers a wide range of services.

Inpatient Hospitalization (Medicare Part A)

Someone can be admitted to a hospital for treatment of their mental health condition. Know that they are limited to 190 covered days over the course of their lifetime if they stay in an inpatient psychiatric hospital.

Otherwise, they are covered for an unlimited number of benefit periods in a general hospital. General hospital stays longer than 60 days will cost them $371 per day from days 61 to 90 in 2021. After 90 days, they can use their 60 lifetime reserve days for Part A inpatient coverage or otherwise pay all costs out of pocket.

Each benefit period charges a deductible of $1,484 in 2021. All provider-based services are covered by Part B with a 20% coinsurance.

Partial Hospitalization (Medicare Part B)

Not everyone needs to stay in the hospital overnight but they may benefit from supervised psychiatric care in an outpatient hospital department or community mental health center. This care may be more intensive than what is available in an office setting.

Part B covers any mental health treatment they receive but does not cover meals, transportation, or support groups that are not considered group psychotherapy. Expect to pay 20% of all services but note that coverage is only available if the Medicare provider accepts assignment.

Office Visits, Counseling, and Therapy

Medicare Part B covers mental health visits with a primary care provider or a psychiatrist. Individual and group psychotherapy are also covered if they are performed by a physician or a qualified licensed healthcare provider. For Medicare to pay, these providers must accept assignment. In that case, there is a 20% coinsurance for each visit.

Family counseling may also be covered but only if it is deemed medically necessary to treat the condition. Medicare does not generally cover marital counseling or pastoral counseling.

Medications

Medicare Part D prescription drug plans are quite comprehensive. While each plan has its own formulary, antidepressants, antipsychotics, and anticonvulsants (many of which are used as mood stabilizers) are protected drug classes.

Essentially, Part D plans will include most, if not all, of these medications on their formularies. Plans are also required to cover at least two drugs in every other drug class.

How much someone pays will depend on their Part D plan’s deductible, coinsurance, or copay rates. Injectable medications administered by a healthcare provider may be covered by Part B.

Medicare Coverage for Depression

An estimated 17.3 million American adults had at least one major depressive episode in 2017. This number represented 7.1% of all U.S. adults. Many others suffered from bipolar disorder, dysthymia, seasonal affective disorder, premenstrual dysphoric disorder, and depressive symptoms related to medical conditions or substance use.

Treatment for these conditions may include medications, psychotherapy, and hospitalization as mentioned above. For severe depression that fails to respond to other treatments, electroconvulsive therapy or transcranial magnetic stimulation may also be an option.

Electroconvulsive therapy (ECT) is a procedure that uses electrical currents to trigger seizure activity in the brain. The procedure is performed under anesthesia. Transcranial magnetic stimulation (TMS), on the other hand, uses alternating magnetic fields instead of electrical currents to stimulate targeted areas of the brain. Seizures are not induced with the procedure and no anesthesia is required.

Both treatments are FDA-approved but are generally reserved for treatment-resistant depression. By changing chemistry in the brain, namely the level of certain neurotransmitters, these treatments aim to reduce the severity of depressive symptoms.

However, neither ECT nor TMS is on the National Coverage Determination list for approved Medicare services. The Centers for Medicare & Medicaid Services may still cover these services, however, if they are reviewed by a Medicare Administrative Contractor in your area and are approved for a Local Coverage Determination.

For care to be covered, it must be sought at a Medicare-approved facility and must meet certain criteria to meet local requirements for coverage. Before seeking treatment, find out what those criteria are to avoid paying all costs out of pocket.

While conventional ECT may be covered by Medicare, multiple ECT (mECT) is not. Instead of triggering a single seizure, mECT induces multiple seizures in a single treatment session. The Centers for Medicare & Medicaid Services considers this procedure too high risk.

Medicare Coverage for Eating Disorders

Anorexia nervosa, bulimia nervosa, and binge-eating disorder are complex psychiatric conditions associated with food restriction, purging behaviors (diarrhea or vomiting), and/or food binging. Not only do they take a toll on mental health, they can lead to malnutrition and medical complications. Reports show one person dies from an eating disorder every 52 minutes.

Eating disorders are not limited to young women. They affect men and older adults too. As many as 13% of women over 50 years old demonstrate eating disorder behavior.

Similar to depression, treatment for eating disorders can include medications, psychotherapy, and hospitalization. Effective treatment often requires a team-based approach to meet the psychiatric and physical impacts of the condition.

Nutrition education, meal planning, and medical monitoring become important to assure adequate nutrition during recovery. Dental care may be especially important if repeated binging has damaged the teeth. Unfortunately, Medicare does not cover routine dental care.

Residential treatment programs aim to provide integrated care under one roof. These programs are intended for people who are medically stable (otherwise, hospitalization may be more appropriate) but who require daily assessments and 24-hour support.

Although these programs do not have a National Coverage Determination, Medicare could cover them locally if a doctor shows that treatment is medically necessary. Coverage often requires a pre-authorization, proof that someone failed to respond to other outpatient treatments, and documentation they remain at high risk for complications and relapse.

There are limited eating disorder centers nationwide that accept Medicare for payment and placement is not guaranteed even when it is. If a pre-authorization is denied, it may be time to seek an appeal.

Medicare Coverage for Opioid Abuse

According to the National Survey on Drug Use and Health (NSDUH), 10.1 million Americans (3.7% of the population) misused opioids in 2019. Looking closer, 9.7 million misused both prescription opioids and heroin, 9.3 million misused prescription medications alone, and 745,000 of them misused heroin alone.

Medicare covers medications, psychotherapy, substance abuse counseling, and drug rehab. This may be done through inpatient hospitalization, partial hospitalization, or intensive outpatient services. Many people also turn to opioid treatment programs.

To qualify for Medicare coverage, opioid treatment programs must be certified by the Substance Abuse and Mental Health Services Administration, accredited by a SAMHSA-approved accrediting body, registered with the Drug Enforcement Administration, and licensed in the state they operate. These programs are the only place someone can be treated with methadone for their opioid dependency.

Interestingly, Part D plans do not cover methadone even though it is FDA-approved for that purpose. This is because methadone must be supplied through an opioid treatment program rather than a retail pharmacy to assure it is safely and appropriately used.

Part D plans do cover other FDA-approved medications for opioid dependency, namely buprenorphine and naltrexone. They are meant to decrease cravings for opioids, curb withdrawal symptoms, and prevent the euphoria or intoxication effects of narcotics.

Buprenorphine also comes in combination with naloxone, a drug used to block opiates from binding to receptors in the brain. Part D plans are required to cover medications to treat opioid addiction. Deductibles, coinsurance, and copays apply.

A Word From Verywell

Mental health conditions are prevalent in America from depression to eating disorders to substance abuse. Unfortunately, few people get the treatment they need. If you are on Medicare, it is important to understand the resources at your disposal. There are a wide number of services available to you when you know you qualify for them. Get the help you need.