Navigating Medicare's Mental Health Coverage: A Comprehensive Guide for Older Adults

Key Points:

• Mental health conditions are prevalent among older adults, and timely treatment is essential.
• Medicare provides coverage for various mental health services, but understanding the details can be complex.
• Experts offer strategies to navigate Medicare's mental health benefits effectively.

The COVID-19 pandemic has significantly impacted the mental health of Americans, including older adults. Recognizing that conditions like depression and anxiety are not a normal part of aging, Kathleen Cameron of the National Council on Aging (NCOA) encourages older adults to seek support and treatment.

However, navigating Medicare's mental health coverage can be challenging. Lindsay Malzone from Medigap.com emphasizes that while many beneficiaries are aware of the coverage, they may lack clarity on specific services, co-payments, and prescriptions.

Medicare, the federal health insurance program for individuals aged 65 and older, consists of two main types:

1. Original Medicare (fee-for-service health plan): Includes Part A (hospital coverage) and Part B (medical coverage).
2. Medicare Advantage: Replaces Original Medicare and is offered by private health insurance companies. Covers most of Part A and Part B through an Advantage Plan.

Understanding the Coverage:

1. Original Medicare:

   • Co-Insurance: Original Medicare has a 20% co-insurance for Part B services, including mental health services. The beneficiary is responsible for 20% of the Medicare-approved amount for covered services.

2. Medicare Advantage:

   • Co-Payments: Medicare Advantage plans typically include co-payments for various services, including mental health services. The co-payment amount varies depending on the plan.
   • Gatekeeper System: Some Medicare Advantage plans may involve a gatekeeper system, requiring a referral from a primary care physician before seeing a specialist, including mental health professionals.

Annual Wellness Visit:

Medicare beneficiaries are eligible for an Annual Wellness Visit (AWV) during their second year of receiving Part B coverage. The AWV is a preventive benefit that assesses overall well-being, including mental health and cognitive function. However, challenges exist with AWV availability and provision.

Covered Mental Health Services:

1. Part A and Part B:

   • Screening and Diagnostic Tests: Medicare Part A and B cover screenings and diagnostic tests for mental health conditions, such as depression, anxiety, and dementia.
   • Medications: Medicare Part B covers a range of prescription drugs, including antidepressants and antipsychotics, for treating mental health conditions.
   • Psychiatric Care: Medicare Part B covers psychiatric care services provided by psychiatrists, such as diagnostic evaluations, medication management, and psychotherapy.
   • Other Professionals: Medicare also covers mental health services provided by other professionals, such as psychologists, social workers, and nurse practitioners.

2. Part D:

   • Prescription Drugs: Medicare Part D covers certain prescription drugs, including antidepressants and antipsychotics, for treating mental health conditions. However, coverage changes year to year, and certain medications may not be covered. Prior authorization may be necessary for initially uncovered drugs.

Expenses Not Covered:

1. Original Medicare:

   • Adult Day Health: Adult day health services, which provide daytime care in a group setting, are not covered by Original Medicare.
   • Outpatient Meals: Outpatient meals provided during mental health treatment are not covered by Original Medicare.
   • Private Duty Nurses: Private duty nurses, who provide one-on-one care in a home setting, are not covered by Original Medicare.

2. Medicare Part A, B, and D:

   • Inpatient Psychiatric Hospitalization: Medicare Part A covers up to 190 days of inpatient psychiatric hospital services. After that, the individual is responsible for self-payment. Extended coverage options may be available through Medicaid, private healthcare, or local programs.

Finding Providers:

Finding healthcare providers who accept Medicare for mental health services can be challenging. However, the pandemic prompted Medicare to approve telehealth services for mental health counseling, expanding the pool of accessible professionals.

Getting Assistance:

1. Medicare Care Compare:

   • The Centers for Medicare and Medicaid Services (CMS) offers a tool called Medicare Care Compare, allowing beneficiaries to search for providers who accept Medicare and compare costs and quality ratings.

2. State Health Insurance Assistance Programs (SHIPs):

   • SHIPs provide local counseling and support to Medicare-eligible individuals, often involving volunteer counselors who are older adults themselves.