Medicare Coverage for Mental Health Services: What's Covered & What Isn't

With age comes the increased possibility of facing mental challenges — some of which can develop into mental health concerns like anxiety and depression. Medicare beneficiaries who are dual-eligible with Medicaid may experience additional financial and social stressors and may be especially vulnerable. Today, more than three years after the start of the COVID-19 pandemic, concerns about mental health and substance use remain high. So, does Medicare cover mental health? The answer is yes, and Medicare coverage continues to evolve to help diagnose and treat changing mental health needs.

All Medicare beneficiaries have access to specific mental health care benefits to cover medically necessary inpatient and outpatient services, whether they are covered by Original Medicare (Part A and Part B) or Medicare Advantage (Part C).

You may be wondering: does Medicare cover therapy? Medicare helps cover the cost of therapy sessions, screenings, and some hospital stays. By law, private Medicare Advantage plans must offer everything covered by Original Medicare and might offer some additional benefits. Each plan is different, so you must check with your plan provider. Suppose you have Original Medicare. An optional private standalone Medicare Part D prescription drug plan can cover mental health prescription medications. With Medicare Advantage, prescription drug coverage is likely part of your plan.

To be covered by Medicare, services must be provided by licensed professionals, such as:

• Psychiatrists or other doctors
• Clinical psychologists
• Clinical social workers
• Clinical nurse specialists
• Nurse practitioners
• Physician assistants

Service providers must accept Medicare-approved payment amounts as full payment and be legally authorized to practice their specialty in the state where services are provided. Beneficiaries with Medicare Advantage plans may have different rules to follow regarding specific networks of doctors and hospitals, prior authorizations, and referrals.

Inpatient hospital care is covered by Medicare Part A (Hospital Insurance) as long as the hospital accepts Medicare and you are admitted by an official doctor's order saying your treatment requires 24-hour inpatient hospital care. Doctors providing you with services within a hospital will most likely be covered by Medicare Part B (Medical Insurance). With Medicare Advantage, these services will be subject to the deductibles, copayments, and coinsurance defined in your plan.

Medicare-covered inpatient treatment can occur in:

• Inpatient psychiatric facilities
• Inpatient rehabilitation facilities
• Acute care hospitals
• Critical access hospitals
• Long-term care hospitals

Unlike other hospital coverage, coverage in a psychiatric hospital is limited: only 190 days of inpatient mental health care is covered in one beneficiary’s lifetime.

Medicare covers the following inpatient services:

• Semi-private rooms
• General nursing
• Meals
• Medications, including methadone for opioid use disorders
• Other hospital services and supplies needed for your inpatient treatment

However, it does not cover:

• A private room, unless medically necessary
• Private-duty nurses
• In-room television or phone (if charged separately from other services)
• Personal care items

For Medicare beneficiaries, mental health-related outpatient care aims to diagnose and treat seniors with mental health disorders like depression and anxiety. You may hear these services referred to as counseling or psychotherapy.

To be covered by Medicare Part B, the licensed providers must accept the Medicare-approved amount for services as full payment. Outpatient mental health services are typically provided in the following settings:

• A licensed health care provider's office
• A hospital outpatient department
• A community mental health center

Medicare Part B helps pay for:

• A one-time "Welcome to Medicare" visit in the first 12 months
• Annual "wellness" visits and depression screenings
• Individual and group psychotherapy with licensed professionals as allowed by your state
• Family counseling (if primarily to help with your treatment)
• Testing to determine whether the treatment is effective
• Psychiatric evaluation
• Diagnostic testing
• Medication management
• Non-self-administered prescription drugs
• Partial hospitalization

Part B includes coverage of outpatient mental health services for substance abuse treatment.

Medicare-covered telehealth services have been extended through the end of 2024 — including two-way audio-only — for diagnosis, evaluation, or mental health or substance use treatment of patients in their homes. Also extended is the removal of a required in-person visit within six months of telehealth services, plus a visit every 12 months.

Partial hospitalization programs (PHPs) are more intense than the treatment you could get in a therapist's or doctor's office and can serve to bridge the gap between inpatient and outpatient treatment. It's a more structured day treatment program at a community mental health center or a hospital outpatient department. Although it's an alternative to inpatient psychiatric treatment, it's still considered an outpatient psychiatric service, primarily because the treatment takes place during the day without you having to stay overnight.

Your doctor must certify and re-certify your need for partial hospitalization, with at least 20 hours of structured, skilled PHP therapeutic services each week. The mental health care providers and the facility must be licensed and accept Medicare assignment for Medicare Part B to help pay for care.

Medicare may help cover:

• Diagnostic services needed before treating
• Individual or group psychotherapy
• Education and training for the patient about their mental condition
• Occupational therapy related to the treatment
• Other staff, including social workers and psychiatric nurses
• Drugs and biologicals for therapeutic use, not self-administered
• Individualized activity therapies for treatment, not recreation
• Family counseling as it affects the treatment

Medicare doesn’t cover the following:

• Standard hospital inpatient services
• Meals
• Self-administered medications
• Transportation to and from treatments
• Job skills counseling unless it's treatment-related
• Support groups for socializing purposes

Intensive outpatient programs (IOPs) offer similar services and therapies to those of PHPs for patients requiring close monitoring and less than 20 hours per week of structured, skilled treatment per week. Treatments are typically three to four hours per day, three days per week. By taking place in the same community-based settings and with the same providers as partial hospitalization programs, it’s easier for patients to step up to PHPs or down to standard outpatient care as needed. Services are covered under Medicare Part B.

These visits are vital in identifying, measuring, and monitoring any symptoms of depression or other mental health conditions so early treatment can occur. Screenings must be performed in your primary care doctor's office or clinic, where staff is available to provide referrals and follow-up treatment.

A one-time "Welcome to Medicare" visit provides a baseline at around age 65, so doctors can compare findings from future visits. After that, your mental health can be reassessed at each annual "wellness visit” with a personalized prevention plan that includes a health risk assessment and depression screening.

The range of mental health services covered by Medicare is broad. However, many complementary therapies considered supportive of mental health by the general population are typically not covered by Medicare — although some might be by your Medicare Advantage plan, so be sure to check with your plan provider. These services are discussed below.

According to the National Institutes of Health, complementary therapies are used together with conventional medicine. If used instead of conventional medicine, therapies are considered "alternative.” Complementary therapies can include:

• Nutritional: special diets, dietary supplements, herbs, and probiotics
• Psychological: mindfulness practices
• Physical: massage, spinal manipulation, etc.
• Combinations of psychological and physical — like yoga, tai chi, acupuncture, or art therapies — or psychological and nutritional, like mindful eating

Although NIH's National Center for Complementary and Integrative Health studies have shown that some of these treatments could be helpful for various conditions, they are not covered by Medicare. Some Medicare Advantage plans may be more flexible in their coverage, so check with your plan provider.

You might ask, "Does Medicare cover counseling?" or more specifically, "Does Medicare cover counseling for anxiety?" In addition to issues such as anxiety and depression, Medicare can help you address many others, including substance use disorders and co-occurring mental illnesses. One requirement is that Medicare counseling and therapy services must be related to a diagnosed mental health condition. Medicare doesn't cover other counseling services, such as for personal growth, life coaching, or general support.

Medicare doesn't typically cover marriage or relationship counseling. However, if family counseling is considered a medically necessary part of your mental health treatment, Medicare Part B helps cover it.

Custodial care is nonmedical assistance with the Activities of Daily Life (ADLs), such as bathing, toileting, dressing, or eating. This assistance may be provided in your home, the community, an assisted living facility, or a nursing home. Whatever the environment, Medicare does not cover such care.

Most long-term care offers support for your personal care needs. However, long-term services can include medical and nonmedical care for those who have chronic health conditions or disabilities requiring ongoing management. Medicare — and insurances such as Medicare Supplement Insurance (Medigap) plans — do not pay for long-term care. Assistance may be available if you qualify for Medicaid or purchase private long-term care insurance.

Medicare Part A and Part B typically don't cover prescription drugs, although Part B will cover some that you can't self-administer. To have prescription coverage, you'll have to buy an optional private Part D prescription drug plan with Original Medicare or have Medicare Advantage coverage, which almost always includes drug coverage.

Mental health treatment includes certain protected drug classes, which include antipsychotics, antidepressants, and anticonvulsants. Drug plans must offer at least two drugs to treat seniors’ common conditions and disorders. However, with few exceptions, all drugs in protected classes must be available. Regardless, it’s essential to check your prescription drug plan's list of drugs — or formulary — to be sure your prescribed drugs are there.

Many mental health prescription drugs are considered controlled substances, so some safety rules apply: such as prior authorization or quantity limits. Another limitation can be step therapy, which requires starting with a lower-cost medication to treat your condition before accessing a higher-cost drug.

Drugs must be FDA-approved and prescribed by your qualified, licensed health care provider.

The first question many people ask is: how much does Medicare pay for mental health? The cost of your mental health services under Medicare depends on the type of coverage — and the specific plan — you have. Medicare coverage is divided into distinct "parts." Let's look at mental health care coverage under each one:

• Medicare Part A (Hospital Insurance) helps cover the mental health services received as an inpatient in a hospital.

• Medicare Part B (Medical Insurance) helps cover mental health services received outside of a hospital, primarily in licensed providers’ offices.

• Medicare Part C (Medicare Advantage), the private alternative to Original Medicare, offers similar benefits as Medicare and may offer additional services. If you need mental health services, make sure you research the plans' benefits.

• Medicare Part D (prescription drug coverage), whether a standalone private plan or part of Medicare Advantage, helps pay for drugs prescribed for a mental health condition.

Specific to mental health services, the following cost-sharing occurs under each part of Original Medicare:

• Part A — which covers inpatient psychiatric hospitalization — incurs the deductibles and coinsurance of standard Part A hospitalization. The one exception is that only 190 days of treatment specifically in a psychiatric hospital are available in a lifetime.

• Part B — which covers outpatient mental health services — incurs the annual Part B deductible and a 20% coinsurance of all Medicare-approved costs for services. Annual depression screenings are the exception because they're free. For partial hospitalization programs, charges may include the daily coinsurance for services in a hospital outpatient or community mental health center setting.

Purchasing a Medicare Supplement Insurance (Medigap) plan will help cover part or all of these shared costs.

Private insurers provide Medicare Advantage plans as an alternative to Original Medicare. These companies are free to design and change their coverage and fees each year if they provide at least everything covered by Original Medicare. Medicare Advantage plans are submitted to Medicare annually for review and approval.

Particularly with mental health services, it's essential to review your plan's coverage for the upcoming year to ensure you have all the support you need, both in treatment and drug coverage. Should something be lacking, you're free to select any other Medicare Advantage plan available in your area during one of the following periods:

• The Annual Enrollment Period (AEP)
• The Open Enrollment Period (OEP)
• A Special Election Period (SEP) you qualify for
• Any other qualifying election period

The need for mental health services can be long-lasting, which makes it essential to find a mental health provider you like and who accepts Medicare. You will want to look at factors such as their experience, qualifications, and the specific services they offer so they align closely with your needs.

If you're wondering how to find a Medicare therapist or other provider, Medicare has a physician comparison website. Here's how to use it:

• Create an account on the Medicare website if you don't already have one.
• Once you've logged in, under "Doctors and clinicians," click "Search for doctors near you."
• Enter your location, plus a specialty, and click "Search."

You may get an extensive list of candidates. Compare their qualifications, then select the one you want. You can also get unbiased, one-on-one counseling and help from your local State Health Insurance Assistance Program (SHIP). Another valuable resource is your local Area Agency on Aging, a gateway organization provided by the U.S. Administration on Aging to connect you to local services.

The U.S. government continually works to improve Medicare coverage for mental health services. For example, legislative efforts are underway to extend coverage to mental health counselors and marriage and family therapists to reduce the challenge of finding a mental health service provider. The National Alliance on Mental Illness (NAMI) is just one of the advocacy organizations seeking to improve access to mental health care and coverage under the different forms of Medicare.

Having the right health care coverage is essential, but it can be even more so when it comes to minimizing the stress around mental health services. OpenMedicare is always available to help you find the right coverage. You can call (844) 910-2061 to be connected to a licensed insurance agent who can help you make your best choice.

Please note that we do not always offer every available plan in your area. As a result, any information we provide is limited to the plans we do offer. Please contact Medicare.gov or 1–800–MEDICARE for information on your options.