November 19, 2024
People of all ages can experience mental or behavioral health challenges. Here’s what’s involved in getting treatment under Medicare. It may be easier than you think.
Many people believe they should just “power through” mental or behavioral health problems. But those problems can get so chronic and severe that they endanger our physical health and hurt our performance at work, at school, or in our family. So it’s not smart to ignore them.
Mental and behavioral health conditions include:
• Anxiety
• Depression
• Eating disorders
• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• Substance use disorders
Any of these can profoundly affect our quality of life and physical health. Luckily, there are many treatments that can make a huge difference.
Medicare covers mental and behavioral health treatments such as:
• Individual therapy
• Group therapy
• Family counseling
• Medication
The Affordable Care Act requires Medicare to cover mental and behavioral health treatments. Medicare has four parts and covers services differently depending on where they’re received.
• Part A covers hospital stays, skilled nursing care, home health visits, and hospice care.
• Part B covers doctor visits, outpatient services, and other medical expenses.
(Parts A and B are known as “Original Medicare.”)
• Part C, Medicare Advantage plans, are offered by private insurance companies and include Part A, Part B, and sometimes Part D coverage along with many extras.
• Part D plans, also offered by private insurance companies, cover prescription drug costs.
Another type of Medicare coverage is a Medicare Supplement plan, designed to help pay for costs not covered by Original Medicare.
Health services received in a doctor’s office are covered by Medicare Part B, including:
• Individual and group psychotherapy
• Psychiatric (medication) management of mental health conditions
• Substance use disorder treatment
After members meet their Part B deductible, they pay 20 percent of the Medicare-approved amounts for outpatient treatment. Treatment in a hospital outpatient clinic may require additional copays or coinsurance.
Many Medicare Advantage plans have a network of mental and behavioral health providers. Those plan members may not have to pay a Part B deductible when seeing in-network providers and will have the same copays that apply to other in-network specialist visits.
Sometimes, people are admitted to hospitals for mental and behavioral health treatment, especially when they need detoxification or 24/7 supervision. Then, their treatment is covered by Medicare Part A.
Care is usually much more costly when it’s received in a hospital instead of an outpatient setting. Usually, a deductible must be met over the first 60 days, followed by a copay of more than $400 per day of hospitalization thereafter.
Medicare Advantage plans typically have different inpatient cost-sharing structures, which vary by plan.
Intensive outpatient programs (IOPs) offer a level of care between outpatient and inpatient treatment and are covered by Medicare Part B. After members meet their Part B deductible, they pay a fixed percentage of the Medicare-approved amount for services received in these programs. They also pay coinsurance for each day of services received in a hospital outpatient setting or community mental health center. Medicare Advantage plans may have a different cost-sharing structure.
Partial hospitalization programs (PHPs) provide structured outpatient psychiatric services totaling at least 20 hours of therapy per week. Patients get treated during the day and don’t have to stay overnight. Medicare coverage for PHPs works just like it does for IOPs.
Some individuals are unable to leave their homes for treatment. Medicare members classified as “homebound” may be 100 percent covered for treatment inside their homes.
Telehealth is health care received via phone or video conference. It’s well suited for mental and behavioral health treatment. Telehealth services are covered under Medicare Part B and work like in-person health practitioner visits: After members’ Part B deductible has been met, they pay 20 percent of the Medicare-approved fee for those services.
Some Medicare Advantage plans have no Part B deductibles and don’t require copays or coinsurance for telehealth visits.
People should work with mental or behavioral health providers they feel comfortable with. Otherwise, their treatment may not succeed. Different treatment modalities and strategies may be more or less effective for one patient than another.
When trying to choose a treatment approach and provider, it helps to:
• Read online reviews
• Ask for referrals from a primary care provider (PCP)
• Get recommendations from a local mental health facility
Sometimes it’s necessary to try more than one provider to find the right fit.
Independence Blue Cross (IBX) Medicare members can locate in-network therapists using the Find a Provider tool.
Before looking for mental or behavioral health providers, Medicare members should check in with their PCP, who can provide initial assessments, prescribe medications, and coordinate specialists’ care. They can also make recommendations based on a patient’s needs.
PCPs also help screen for mental and behavioral health problems during a patient’s first “Welcome to Medicare” evaluation and at each annual wellness visit. These visits are covered 100 percent by Medicare.
Medicare Part D prescription drug plans cover psychiatric medications just like other prescription drugs — according to the tier those drugs occupy in the plan’s formulary.
Medicare members have access to treatment for mental and behavioral health issues. Medicare covers these treatments differently depending on where they’re received. Medicare Advantage plans have their own cost-sharing structures for these services.
IBX Medicare plan members may contact the Member Help Team at the phone number on the back of their member ID card with any questions about their benefits or how to access care.
People interested in IBX Medicare Advantage or Medicare Supplement plans can shop here.
This content was originally published on IBX Insights.
