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Mental health and substance abuse disorder services are vital. And that is more-so the case for elderly citizens. Research showed that as many as 20% of adults aged 65 and older reported symptoms of anxiety and/or depression. Furthermore, mental illness was observed in approximately one in four Medicare beneficiaries. Yet, only 40% to 50% of these beneficiaries received treatment.

Mental illness rates are notably higher in beneficiaries under 65 qualifying for Medicare due to disability, low-income beneficiaries, and those from American Indian/Alaska Native and Hispanic communities. Given the prevalence and necessity for intervention, it is crucial to understand the mental health services covered by Medicare.

Medicare Coverage Overview

Mental health and substance use disorder services are covered, to some degree, under Medicare Parts A and B. Part A covers inpatient services required for acute or severe symptoms, including diagnostic testing, lab work, specialist consults, medications, and nursing care.

Outpatient services under Part B range from minimal therapy to partial hospitalizations. They include psychiatric evaluations, medication management, and psychotherapy. It should be noted that in 2008, the U.S. government equalized coverage for mental health outpatient services with other Part B benefits.

Financial Aspects and Limitations

A senior analyzing the cost of mental health services for a loved one.
Although Medicare provides extensive coverage, the financial burden associated with inpatient mental health services under Part A can be significant.

Although Medicare provides extensive coverage, the financial burden associated with inpatient mental health services under Part A can be significant. There is a $1600 deductible per benefit period and increasing copays after the first 60 days of admission. For outpatient mental health services under Part B, a $226 deductible is required, after which Medicare covers 80%, leaving the remaining 20% for the patient.

One should note that conveniences, such as private inpatient rooms, televisions, phones, and personal care items, are not covered by original Medicare unless medically necessary. Other services not covered on the outpatient side when there is partial hospitalization include meals, transportation, and job training. Lastly, it’s worth noting that Medicare Parts A and B generally do not cover prescription drugs for mental health except under specific conditions, necessitating a Medicare Part D plan.

Supplemental Coverage

Medicare Advantage plans are cover the same set of mental health services as original Medicare but offer additional benefits like reduced cost sharing for those with mood disorders or opioid use disorders. However, the scope of these benefits is not widely known, and only 6% to 12% of enrollees have access to such benefits.

Challenges and Potential Solutions

There are several challenges and limitations to Medicare’s mental health coverage. One such challenge is a lifetime limit of 190 total days for inpatient psychiatric hospital care. This can pose a barrier for those with chronic mental illnesses. Another challenge is a lack of access to in-network mental health providers for Medicare Advantage beneficiaries.

Solutions to these issues are currently in consideration. Legislation has been proposed to remove the 190-day limit and supervision requirements for clinical psychologists. There is also talk of improving access to providers, particularly for rural beneficiaries. This is because, with a declining number of providers accepting Medicare, the demand for psychiatrists significantly outstrips supply.

Another proposed solution is for the CMS (Centers for Medicare & Medicaid Services) to incentivize plans for updated mental health provider directories. There would also be a move toward planning criteria for network adequacy to improve access to mental health care.

When we talk about “network adequacy,” we are referring to the standards and requirements that health insurance plans must meet to ensure that their members have sufficient access to healthcare providers. This includes ensuring that there are enough healthcare providers in the network to meet the healthcare needs of the members and that these providers are accessible in terms of location and appointment availability. 

In the face of these challenges, Medicare has been working to expand coverage for mental health services. Beginning in 2024, the government agency will reimburse licensed professional counselors, a welcome move that could help address provider shortages.