Medicare and mental health

CMS NEWS RELEASE

By David Sayen

Mental health problems like depression and anxiety can affect anyone’s life at any age. If you think you have a mental health condition, Medicare may be able to help.

The symptoms of mental health issues include feelings of sadness, emptiness or hopelessness; a lack of energy; and difficulty concentrating or sleeping. You might find yourself losing interest in activities you used to enjoy, or even having thoughts of ending your life.

If you have any of these symptoms, talk to your doctor or other health care provider.

Medicare’s coverage of mental health includes outpatient and inpatient treatment, as well as prescription drugs.

If you get your Medicare benefits through a Medicare Advantage health plan, check your plan’s membership materials. Or call the plan for details about your Medicare-covered mental health benefits.

If you have Original Medicare, Part A covers inpatient care and Part B covers outpatient care. Part D covers medications you may need.

Part A helps pay for mental health services given in a hospital that require you to be admitted as an inpatient. These services can be provided in a general hospital or in a psychiatric hospital that cares exclusively for people with mental health conditions.

How much do you pay? Medicare measures your use of hospital services in benefit periods. A benefit period begins the day you go into a hospital and ends after you’ve had no hospital care for 60 days in a row. If you go into a hospital again after 60 days, a new benefit period begins, and you must pay a new inpatient hospital deductible.

There’s no limit to the number of benefit periods you can have when you get mental health care in a general hospital. You can also have multiple benefit periods when you get care in a psychiatric hospital, but a lifetime limit of 190 days applies to inpatient psychiatric care.

For each benefit period, you pay a $1,156 deductible (in 2012) and no coinsurance for days 1–60. For days 61–90 of each benefit period, your cost would be $289 per day.

Medicare Part B helps cover services by doctors and other providers if you’re admitted as a hospital inpatient. You pay 20 percent of the Medicare-approved amount for these services while you’re an inpatient.

Part B also helps pay for outpatient visits to psychiatrists or other doctors; clinical psychologists, social workers, and nurse specialists; and other professionals. (Make sure your provider accepts Medicare payment before you schedule an appointment.)

Outpatient services are covered by Part B as well. These include psychiatric evaluation, medication management, individual and group psychotherapy with doctors or certain other licensed professionals and family counseling if the main purpose is to help with your treatment.

For outpatient care, you’ll have to pay the Part B deductible, which is $140 this year. After that, how much you pay depends on whether the purpose of your visit is to diagnose your condition or to get treatment.

When you visit a doctor or other professional diagnostician, you pay 20 percent of the Medicare-approved amount.

For outpatient treatment such as psychotherapy, you pay 40 percent of the Medicare-approved amount in 2012.

(Recent legislation reduced these co-insurance amounts to keep them in line with other types of medical services; mental health co-insurance will drop to 35 percent next year and 20 percent in 2014.)

Part B also covers “partial hospitalization” in some cases. This is outpatient psychiatric treatment that’s more intense than the care you get in a doctor’s or therapist’s office. It’s provided during the day, usually through hospital outpatient departments and community mental health centers.

Many Medicare Advantage plans cover prescription drugs. If you have Original Medicare, you can join a Part D drug plan.

Medicare drug plans aren’t required to cover all drugs. However, they must cover all or almost all anti-depressant, anticonvulsant and antipsychotic medications.

David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii and the Pacific Trust Territories. You can get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

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