Is Therapy Covered by Medicare? Know Your Benefits
Figuring out if therapy is covered by Medicare and how it all works can feel a little overwhelming. It’s one of those things many people need but often feel unsure about asking.
But you are in the right place to get the answers. We’ll break it down simply so you can get the mental health support you need. Is therapy covered by Medicare? Yes, but there are details that affect what is and isn’t covered. We’ll walk through each aspect below.
Medicare and Mental Health: Understanding the Basics
Medicare does cover many outpatient mental health services, but the specific coverage depends on your situation – including whether you have Original Medicare or a Medicare Advantage Plan.
Original Medicare
Let’s start with Original Medicare, which consists of Part A (Hospital Insurance) and Part B (Medical Insurance).
Inpatient Mental Health Care (Part A)
Medicare Part A covers inpatient mental health services received in a hospital setting, either a general hospital or a psychiatric facility.
This applies to situations when you’re formally admitted to the hospital for your condition, not just outpatient visits. This coverage helps cover costs for semi-private rooms, meals, nursing care, medications, and therapy sessions that are part of your inpatient treatment. Keep in mind, though, this coverage has limitations, especially if you are receiving treatment in a psychiatric hospital. While you can have unlimited benefit periods in a general hospital, Part A only covers a maximum of 190 days total during your lifetime in a freestanding psychiatric facility.
Outpatient Mental Health Care (Part B)
Medicare Part B is what you will use for outpatient therapy services, such as individual and group psychotherapy. These services are usually offered in settings such as a therapist’s office or a community mental health center.
Your costs are as follows:
- Yearly Depression Screening: Medicare will pay 100%.
- Visits to Diagnose/Treat Condition: After you meet the Part B deductible ([medicare_costs value=partb-deductible] in [medicare_costs value=medicare-cost-year]), you are responsible for 20% of the cost.
- Hospital Outpatient Costs: If services are received in an outpatient setting at a hospital you may be responsible for an additional copayment or coinsurance amount.
Medicare Advantage (Part C)
Medicare Advantage Plans are offered through private insurance companies. Medicare Advantage Plans are required to cover at least the same services as Original Medicare, but some may provide additional coverage such as telehealth.
Does Medicare Cover Counseling?
Yes, Medicare Part B covers counseling from various licensed mental health professionals – as long as they participate in Medicare. This includes visits with:
- Psychiatrists
- Physician Assistants
- Clinical psychologists
- Clinical nurse specialists
- Nurse practitioners
- Clinical Social Workers
- Doctors
As with many healthcare services, ensuring your provider accepts Medicare assignment will help keep your costs down. “Assignment” means they’ve agreed to be paid directly by Medicare and to accept the Medicare-approved amount for services. To confirm a provider takes Medicare, use the Physician Compare page or call 1-800-MEDICARE.
Specific Types of Mental Health Services Covered by Medicare
Now, let’s discuss specifics. Here are examples of services often included under Medicare coverage:
Inpatient Services
When more structured care is needed, Medicare covers services provided in these facilities:
- Inpatient Psychiatric Facilities
- Critical Access Hospitals
- Hospital Psychiatric Units
There are differences in coverage between Original Medicare’s Parts A and B, and this is a perfect example of how. Your stay at one of these facilities is paid for through Medicare Part A (Hospital Insurance). Whereas the fees charged by the psychiatrists and specialists are paid by Medicare Part B.
Outpatient Services
Outpatient mental health involves assessment and treatment of several mental health conditions like depression and anxiety.
| Service | Requirements/Coverage Details |
|---|---|
| Yearly Depression Screenings | Offered once per year; must be done by a primary care doctor’s office or primary care clinic who accepts assignment. |
| Diagnose/Treat Mental Illness | The provider must accept Medicare Assignment; 20% coinsurance for each appointment once your deductible has been met. |
| Psychiatric Hospital (Outpatient) | For services or supplies given; Must be medically necessary for diagnostic tests; The expectation must be that you will get better; The care must be provided on a planned basis with a written plan listing what type of services you need, for how long, and what your healthcare provider thinks will happen to you because of these services (this is called a plan of care) |
Partial Hospitalization Program (PHP)
PHPs act as a bridge between inpatient and outpatient services, providing more intensive structured support without requiring a hospital stay.
Medicare covers these if your doctor or other healthcare provider states that it is medically necessary. Your provider would have to document that, without it, you would require inpatient hospitalization. Medicare covers these programs when offered by hospital outpatient centers as well as Community Mental Health Centers (CMHCs).
Community Mental Health Centers (CMHCs)
CMHCs play a critical role in offering an alternative to inpatient psychiatric care, especially when patients do not meet the criteria for admission but need support above what traditional outpatient care can offer.
They can serve as an excellent point of contact for mental health support and referral, especially in times of crisis as they provide round-the-clock support. CMHC services may include assessments and connection to resources, such as support groups or even inpatient facilities. They are staffed to offer other options in line with patient needs, such as:
- Partial Hospitalization
- Day Treatment
- Rehabilitation
Telehealth
Many people now find it more accessible to address mental health concerns using technology. Telehealth covers mental health services such as therapy, medication management, and psychiatric evaluations through real-time video conferencing. Medicare covers outpatient mental health services through telehealth, meaning the service is here to stay.
During the peak of the COVID pandemic, Medicare changed its rules allowing more telehealth options for various needs due to increased isolation and challenges for those, particularly the elderly, to safely get the services needed in person.
You may also use this option under Medicare Advantage, although as each plan is different, this is important to verify.
Prescription Medication
While Medicare Parts A and B do not include prescription drug coverage, you may have access to mental health medications through a Medicare Part D prescription drug plan, or it might be included in a Medicare Advantage plan that covers prescription medication (Medicare Part C). Not all prescription drugs will be covered by each plan, which is why it’s so important to review your plan’s “formulary” (the list of medications a plan covers).
Medicare and Substance Use Disorder (SUD)
Substance use disorder treatment is treated like other medical conditions such as diabetes. Both inpatient and outpatient treatment options may be covered through your plan, and there may be no out-of-pocket cost for care as long as your provider is enrolled with Medicare.
Welcome to Medicare and Yearly Wellness Visits
When you’re first eligible for Medicare, be sure to take advantage of your free “Welcome to Medicare” preventive visit within the first year you are enrolled. Family counseling can help get you on track for mental health by reviewing potential risk factors for depression. After the first year, these visits are called “Wellness Visits” and are offered each year after that. Take this opportunity to address your mental and physical health with your primary care provider as a way to catch potential concerns in their early stages or even prevent them from arising at all.
If they see an area that requires further evaluation and/or treatment they will refer you to the appropriate specialist, who will likely be covered by Medicare Part B as a specialist. Don’t avoid seeking support if you need it, reach out to one of the resources included below.
Resources
If you or someone you know is in crisis, call or text 988 or chat 988lifeline.org.
If you or a loved one is struggling with mental health concerns, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area.
You can also connect with a counselor through web chat at 988lifeline.org.
The 988 Suicide & Crisis Lifeline, formerly known as the National Suicide Prevention Lifeline, is the federal government’s free 24-hour hotline.
The nonprofit Crisis Text Line also has 24/7 counselors.
FAQs about is therapy covered by Medicare
What Does Medicare Not Cover?
Medicare covers a wide array of mental health care services and treatment, however there are still some exclusions to keep in mind, including but not limited to:
- Meals (except if you are admitted to a hospital as an inpatient, under Part A coverage).
- Transportation to and from treatment or services (for both inpatient and outpatient).
- Support Groups – this is different than group therapy, which *is* covered.
- Testing/Job Skills Training – unless it is specifically deemed as part of your mental health treatment.
Why Is Seeking Help From Licensed Mental Health Professionals Important?
While support groups and community resources are a valuable tool for gaining peer support, education, and connection, sometimes we need help above what these resources can provide. Getting help from qualified healthcare providers like those we’ve discussed can mean all the difference in the world as they have additional training and knowledge. They are able to evaluate your situation through the lens of education and experience in treating these issues. Many can also prescribe medication or make referrals to specialists if your situation requires it.
Conclusion
Determining if therapy is covered by Medicare requires understanding the many facets of the program. However, it does not need to feel scary or overwhelming. Take a moment to reflect on your individual needs and reach out to resources provided by Medicare such as your plan directly or those provided on Medicare.gov. With these resources and an understanding of your needs, navigating this important part of health will start to feel manageable and lead to improved well-being.