How Does Medicare Cover Counseling Services?

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Key Takeaways:

  • Medicare covers annual mental health and depression screenings at no cost to you.
  • Most types of outpatient therapy and counseling services are covered if you meet the Medicare guidelines.
  • Medicare may cover partial hospitalization and inpatient mental health treatment if your doctor deems it as medically necessary.
  • Part D prescription drug plans must cover antidepressant and antipsychotic medications.

Growing older brings along with it a whole new set of physical and emotional challenges. For this reason, it’s only natural to feel anxious or depressed from time to time.

According to the CDC
, about 20% of adults age 55 and older experience some mental health concern. That’s why it’s so important to know how Medicare covers various therapies and counseling services.

The good news is that mental health services are covered by Medicare, whether you choose Original Medicare or a Medicare Advantage plan. Although the specific benefits vary a bit from one to another, you can rest assured that Medicare can and will help you get the care you need. This article explains the more specific details you need to know regarding Medicare coverage and counseling services.

When Does Medicare Cover Counseling Services?

Medicare has comprehensive mental health care benefits for both inpatient and outpatient counseling services. In order to be covered, your counseling or therapy must be provided by a licensed healthcare professional, such as:

  • A psychiatrist or other medical doctor
  • A clinical psychologist
  • A clinical social worker
  • A clinical nurse specialist or nurse practitioner
  • A physician’s assistant

It is important to note that Part B will only pay for therapy and counseling services if your provider accepts Medicare assignment.

Medicare Coverage For Mental Health Screenings

Medicare covers services to help your doctor identify your risk factors for depression and other mental health concerns. These services are covered under Part B as part of your preventive care benefit. In order to be covered, these mental health screenings must be done by a primary care doctor who can make referrals for therapy or counseling if needed and follow your treatment progress. 

Medicare Mental Health Screening Benefits

Depression screening

  • Assesses your risk for depression
  • Medicare covers one per year
  • You pay nothing if your provider accepts assignment
  • Deductible does not apply

Wellness visit

  • Includes mental health assessment and assessment for Alzheimer’s and cognitive decline
  • Medicare covers one per year
  • You pay nothing if your provider accepts assignment
  • Deductible does not apply

Welcome to Medicare visit

  • Includes mental health and safety assessment
  • Medicare covers one within the first 12 months of Medicare enrollment
  • You pay nothing if your provider accepts assignment
  • Deductible does not apply

Medicare Coverage For Outpatient Mental Health Services

Many mental health conditions can be managed with outpatient therapy. This therapy can consist of one-on-one visits with a psychotherapist or counselor, group therapy, or family counseling. Part B covers all of these services, including family counseling, as long as your provider deems each as being medically necessary for treating your condition.

Medicare doesn’t cover all types of therapy, however. For instance, marriage counseling isn’t typically covered by Medicare. Counseling provided by a non-licensed professional, such as a member of the clergy, also isn’t covered by Medicare.

Another noteworthy piece of information  is that there may be coverage limits on Medicare’s counseling benefit. For example, Part B only pays for four alcohol misuse counseling sessions per year. Medicare also requires that your counseling or therapy sessions take place in a doctor’s office or other Medicare-approved facility.

Medicare pays 80% of the allowable charges for counseling and therapy after you meet your Part B deductible.

Medicare Coverage For Partial Hospitalization Programs

Partial hospitalization or day treatment programs may be covered by Medicare if they meet certain requirements. Specifically, your doctor must certify that you need this level of care and that you would need inpatient psychiatric care if a day treatment program wasn’t available.

Other Medicare coverage requirements for partial hospitalization programs include:

  • The program must include at least 20 hours per week of counseling and therapy services
  • Treatment must be supervised by a licensed physician
  • The program must offer multiple types of therapy, including individual and group counseling
  • Therapy must be provided by licensed professionals
  • The doctor must develop an individual treatment plan with measurable goals
  • The need for partial hospitalization must be reviewed at least every 30 days

Part B pays a percentage of allowable charges for partial hospitalization programs after you meet your Part B deductible. You pay a percentage of allowable charges plus a daily coinsurance for each day of treatment.

Medicare has comprehensive mental health care benefits for both inpatient and outpatient counseling services.

It is important to note that Medicare doesn’t cover meals in a day treatment program or transportation to and from the facility. 

Medicare Coverage For Inpatient Mental Health Services

In some cases, inpatient counseling and mental health services are the best options to help you get better. If your doctor recommends inpatient mental health care, Medicare will then cover most of your costs.

Part A pays allowable charges after you pay your Part A deductible. There is a lifetime inpatient mental health benefit of 190 days.

Does Medicare Cover Counseling if You Have Medicare Advantage?

Medicare Advantage is private insurance,  which means that your coverage may be different depending on the specific plan you choose. At a minimum, Medicare Advantage must provide the same level of counseling and therapy coverage as Original Medicare.

Your Medicare Advantage plan may charge a flat copayment for counseling and therapy services instead of a percentage-based coinsurance. You may also need to get counseling from providers in the plan’s approved network of providers.

Also noteworthy, some Medicare Advantage plans require referrals and prior authorization for therapy and counseling services.

If you have a Medicare Advantage plan, check your plan brochure for specific information about mental health coverage. You can also call your plan’s Member Services department for further help.

Does Medicare Cover Therapy with Prescription Drugs?

If you receive mental health care services in an inpatient setting, Part A covers the medications your doctor prescribes.

If you receive outpatient counseling and therapy services, Part B typically doesn’t cover any prescription drugs your doctor recommends.

If you have a Part D prescription drug plan, medications for treatment for mental health conditions are usually covered. Medicare requires all Part D plans to cover all antidepressant and antipsychotic medications approved by the FDA.

As Part D is private insurance, your copayments and deductible are set by the insurance company. You may have coverage restrictions with certain medications. For example, your plan may first require a trial with a less expensive medication before it pays for a more expensive one. You may need prior authorization for psychiatric medications, and there may be quantity limits that restrict how many doses you can get at one time.

You can find specifics about your prescription drug coverage in your plan formulary. The formulary is a list of medications covered by your plan and what you pay for each one. It also lists any restrictions and special requirements associated with each drug, such as prior authorization required for use and/or procurement.

Getting the Counseling You Need

You don’t have to wait for your annual wellness visit or depression screening to talk to your doctor about mental health care. Medicare pays for visits with your primary care doctor if you want to talk about your mental health concerns now.

So, if you feel anxious or depressed, make an appointment with your doctor without delay. Medicare pays for mental health evaluations and tests to help your doctor diagnose a potential problem. Medicare’s comprehensive mental health coverage means you’ll get the counseling services you need to feel your best.

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