Medicare Mental Health Benefits for Texans
Health Insurance Medicaid & Medicare
Mental health is every bit as important to individuals as cardiovascular health and pulmonary health. Just as anyone can develop a cardiovascular health problem, anyone can also develop a mental health problem. You may need to talk to your doctor or health care provider to get help if you are suffering from a mental health condition.
And help is available. If you are suffering from feelings of hopelessness, have a lack of energy, or have trouble concentrating; if you have trouble sleeping, little appetite, or if you are increasing your use of alcohol or drugs, there may be services, programs, or treatments available to help you overcome your condition. And, if you have Medicare, it will help cover the cost of the mental health care, including the cost of prescription drugs you may need to treat the condition.
What is Medicare?
As it currently exists, Medicare provides health insurance to help cover hospital-type services, such as in-patient hospital care, critical access hospitals, skilled nursing facility care, hospice care, and some home health care. Those types of services are covered under what is called Medicare Part A.
Medicare insurance also helps cover the cost of doctor’s services as well. These types of services are covered under what is called Medicare Part B. For example, a doctor’s appointment, outpatient care, and many preventative services are covered under Medicare Part B.
Since 2006, Medicare also helps cover the cost of prescription drugs as well. That coverage is known as Medicare Part D.
What is Medicare Advantage?
Like “original” Medicare, the Medicare Advantage program is regulated by the federal government. However, unlike original Medicare, the insurance offered under the Medicare Advantage program is offered by private insurance companies. Basically, this is an alternative way to get Part A, Part B, and Part D coverage. The Medicare Advantage program is also referred to as Medicare Part C.
If you get coverage under a Medicare Advantage program, it will provide coverage for hospitalization (Part A), for doctor’s services (Part B), and for prescription drugs (Part D). Many plans may offer coverage for things like vision, hearing, and dental. Significantly, Medicare Advantage plans cover mental health services as well.
What are “mental health services”?
Mental health services help diagnose and treat people with mental health disorders like depression and anxiety. An example of mental health services would be counseling or psychotherapy.
What mental health services does Medicare cover?
Medicare Part B covers mental health services and visits provided outside a hospital. For example, a doctor’s office, a hospital outpatient department, or community health center. The coverage extends to providers that accept assignment, such as by:
- Psychiatrists or other doctors
- Clinical psychologists
- Clinical social workers
- Clinical nurse specialists
- Nurse practitioners
- Physician assistants
What is Medicare “assignment”?
An assignment is an agreement by a doctor or health care provider to be paid directly by Medicare, to accept the payment amount Medicare approves for services, and not to bill the patient (you) for anything other than the Medicare deductible or coinsurance amount. Providers that participate in Part B must accept assignment.
What types of mental health services does Part B cover?
Medicare Part B helps pay for a variety of outpatient mental health services. Here is a list of examples:
One depression screening per year.
Individual and group psychotherapy
Testing that may be necessary to identify treatment options
A yearly wellness visit
Does Medicare cover opioid treatment programs?
Medicare covers opioid use disorder treatment services and programs, including treatment (such as counseling) and medication (such as methadone).
Does Medicare cover alcohol abuse counseling?
Medicare covers one alcohol misuse screening per year for adults. If your provider determines that you are misusing alcohol, you can get up to four counseling sessions per year (in a primary care setting, like a doctor’s office).
What will I have to pay?
In general, after you pay your annual Part B deductible, you pay 20% of the Medicare-approved amount for covered services. If you have a Medicare Supplemental Insurance (Medigap) policy, tell your healthcare provider, so your bills get paid correctly.
Does Medicare Part A provide mental health coverage?
Medicare Part A covers mental health services that you receive in a hospital as an inpatient. No matter what type of hospital you choose (a general hospital or a psychiatric hospital), Part A will help cover inpatient mental health services.
What types of charges does Part A cover?
Medicare Part A covers semi-private rooms, meals, general nursing, drugs, and other hospital services and support you receive as inpatient treatment.
As an inpatient, you will be responsible for paying a deductible and, after day 60 of the benefit period, you will pay a coinsurance amount for each day of services. The coinsurance amount increases after the 90th day of the benefit period. You are also responsible for 20% of the Medicare-approved amount for the mental health services you get from the hospital as a hospital inpatient.
Are there time limitations for Part A coverage?
The benefit period for Part A type services begins the day you are admitted as an inpatient and ends after you haven’t had any inpatient hospital care for 60 days in a row. If you are admitted to a hospital again after 60 days, a new benefit period begins, and you must pay a new deductible for services you receive.
There is no limit to the number of benefit periods you can have for mental health care in a general hospital. You can also have multiple benefit periods in a psychiatric hospital, but there is a lifetime limit of 190 days for inpatient psychiatric hospital services.
What does Part D cover?
To get Medicare Part D coverage, you must join a plan that offers drug coverage. Medicare drug plans are run by private companies that follow Medicare rules. The plan costs and coverages vary, but nearly all antidepressants and antipsychotic medications are required to be part of the drug formularies.
What is a drug formulary?
Most Medicare drug plans have a list of drugs that the plan will cover. The list is called a formulary. Medicare drug plans are not required to cover all medications, but they are required to cover antidepressants, anticonvulsants, and antipsychotic medications (with limited exceptions).
Where can I get more information?
Texans have various resources available to help navigate these various Medicare programs and options.
First: Texas Health and Human Services. Contact them by calling 800-252-9240, which is the Texas Medicare Help Line.
There is also a network of local support centers for seniors known as Texas Area Agencies on Aging. They can help you get specific information and help get you enrolled. Contact them at Area Agencies on Aging Directory | HHS (texas.gov).
And if you have legal questions about Medicare, you can contact the Legal Hotline for Texans at 800-622-2520.
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