Older Americans Are Wondering: What Does Medicare Cover for Mental Health?

The pandemic has put a strain on the mental health of many Americans, and the elderly are no exception. While those 65 and older experienced mental health concerns, such as depression, anxiety, sleep disorders, and suicide ideation before the pandemic, Kathleen Cameron, senior director of the Center for Healthy Aging at the National Council on Aging (NCOA), says COVID-19 impacted the mental health of older adults in crucial ways. 

“[Older] adults have been impacted pretty significantly, particularly by the social isolation and loneliness that they experience that could have exacerbated existing conditions that they had or in some cases, new diagnosis of depression, anxiety, sleep problems happened during the pandemic,” she says.

Although the World Health Organization (WHO) reports that about 15% of adults aged 60 and over live with a mental disorder, conditions like depression and anxiety are not a normal part of aging, Cameron says. She notes that many older adults might feel like they need to accept and manage these conditions on their own. “But there are true clinical symptoms of depression that can be effectively treated and we’ve seen there are pharmacologic and non-pharmacologic approaches that are highly effective in helping older adults with mental health conditions, so they can lead as high-quality life as possible.” 

For those on Medicare, knowing what mental health services are covered can make seeking help more daunting. “Medicare beneficiaries might be aware that they have some sort of mental health coverage, but may not understand what it entails regarding services, co-payments, and prescriptions,” says Lindsay Malzone, Medicare expert at Medigap.com. 

To help navigate the ins and outs of Medicare, experts share insight. 

Original Medicare Versus Medicare Advantage

Nearly half of Medicare beneficiaries are enrolled in Medicare Advantage plans, says Ann Kayrish, senior program manager for Medicare at NCOA, so understanding the difference is important.

Original Medicare is a fee-for-service health plan that has two parts: Part A (hospital Insurance) and Part B (medical Insurance). Medicare Advantage plans still provide most of Part A and Part B coverage, but the benefits are covered by the Medicare Advantage Plan, not Original Medicare. 

When it comes to mental health benefits, Kayrish says keep the following in mind:

• Original Medicare includes a 20% co-insurance and if you have a supplement, it will most likely cover it.
• Medicare Advantage includes the same type of coverage and a co-payment.
• Medicare Advantage may require a gatekeeper system, which means your primary care
  physician has to refer you to mental health care.

Annual Wellness Visits

On the second year of receiving Medicare Part B, Malzone says beneficiaries are eligible for a free Annual Wellness Visit (AWV), which is a preventive benefit intended for doctors to review with their patients how well-being impacts everything from mental health, cognitive function, fitness levels, and illness prevention.

The AWV is separate from an annual physical exam that monitors for conditions like heart disease and diabetes. According to Cameron, the AWV includes a screening and assessment for a number of health and social issues that older adults may be dealing with including depression, anxiety, and substance use. During the visit, the doctor might ask you to fill out a questionnaire called a Health Risk Assessment, which includes questions that can initiate a prevention plan specific to you. 

“There are some challenges with it [such as] it’s not being offered and older adults don’t know about it, and it’s really hard for many healthcare providers to provide it because they’re dealing with other issues with their patients,” Cameron says.

Asking your doctor about the AWV is a good way to ensure you receive the benefit.

Mental Health Care, Screenings, and Treatments Covered by Medicare

Malzone says Medicare mental health benefits that are primarily covered by Medicare Part A and B include:

• Annual screenings
• Diagnostic lab tests
• Some prescription drugs
• Psychiatric care
• Psychotherapy
• Partial hospitalization
• Doctors and psychiatrists
• Physician assistants
• Clinical psychologists
• Clinical social workers
• Clinical nurse specialists
• Nurse practitioners

Mental Health Services Not Covered by Medicare

While Medicare covers mental health, Malzone points out that there are exclusions, limitations, and out-of-pocket costs. Some mental health expenses not covered by Original Medicare include: 

• Adult day health
• Report preparation
• Outpatient meals
• Hemodialysis for treating schizophrenia
• Transportation
• Private duty nurses
• Pastoral counseling

Coverage for Inpatient Services

If you receive mental health care in a psychiatric hospital rather than a general hospital, Medicare Part A will pay for up to 190 days of inpatient psychiatric hospital services during your lifetime. “After that, you’ll spend 100% out of pocket for your care,” says Malzone. However, after lifetime reserve days are exhausted, she says options to receive mental health coverage include Medicaid,
private healthcare coverage, or a county-specific or local program. 

“Contact your local community mental health and substance use walk-in clinic to inquire or the county crisis line in your area,” Malzone says.

Kayrish notes that current legislation is underway to try to extend the 190 days of coverage.

Prescription Drug Coverage

Medicare Part D covers some medications, such as antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers. Some medications are also covered through Medicare Advantage plans too, says Kayrish. 

“Know if the drugs you take are on the Part D plan because not all drugs are going to be covered. Work with your provider to see if there is a generic version or work with your plan to see if there is a formulary exception,” she says.

If only certain medications work for you, Cameron says find out if those drugs are covered. If they aren’t, “there is a prior authorization process where the doctor can contact Part D and request another medication be covered, but that process takes a lot of time and energy,” she says. 

And take note that plans change every year, which means coverage for drugs may change from year to year.

Coverage Doesn’t Guarantee Access

While Medicare covers mental health care, finding providers who accept Medicare as a form of payment for these services may be a struggle. “There’s been an ongoing issue that folks can’t seem to get a professional who accepts Medicare as payment for the mental health counseling and services they do deliver,” says Kayrish. 

The good news is that the demand and need for mental health services during the pandemic, prompted Medicare to approve telehealth services for mental health counseling, expanding the pool of accessible professionals. “During the public health emergency, you can have an audio only type of visit with a mental health professional and that would be covered by Medicare,” says Kayrish, noting that the visits may still require out-of-pocket costs. 

Where To Find Help Understanding Medicare

The Centers for Medicare and Medicaid Services offers a tool called the Medicare Care Compare that provides a list of Medicare mental health providers who accept Medicare. You can also call Medicare at 1-800-633-4227 or visit a Medicare local office to get in-person assistance. 

Kayrish recommends turning to your State Health Insurance Assistance Program (SHIP), which aims to provide local, in-depth, and objective insurance counseling and assistance to Medicare-eligible individuals, their families, and caregivers. In addition to giving people an introduction to Medicare and help enrolling, she says many of their volunteer counselors are older adults. 

“In some ways, if you call and end up talking with someone who is of your peer group, that might make the ability to ask questions about mental health coverage a lot easier,” says Kayrish.