Medicare's Mental Health Coverage

A number of my clients depend on the expertise of geriatric psychiatrists to appropriately address depression, anxiety, or agitation associated with dementia.  They see their doctors and counselors/social workers in inpatient as well as outpatient settings.  How are these services paid for?  Traditional Medicare, like most health insurance plans, provides mental health benefits (Medicare Advantage plans may provide different coverage). The coverage differs, though, for inpatient and outpatient services.

If a Medicare beneficiary receives inpatient services in a psychiatric hospital (i.e., Peachford Hospital or Ridgeview Institute in the Atlanta area), they have the same deductibles and co-pays as for general hospitals.  The big difference, however, is that Medicare beneficiaries have a 190-day lifetime max for inpatient services in a psychiatry hospital.  Beneficiaries can also seek mental health services at a psychiatric unit within acute care hospitals (i.e., Emory's Wesley Woods or Eastside Heritage).  Here is the list of deductibles and co-pays for hospital coverage:

Hospital deductible: $1,156 (waived if the beneficiary is admitted to a psychiatric hospital within 60 days of being discharged from a different hospital) 
Hospital co-pay for days 61-90: $289/day
Hospital co-pay for days 90-150: $578/day

As for outpatient coverage, Medicare will pay 80% of the initial visit to a licensed psychiatrist to determine diagnosis; this is similar to the payments made to other doctors.  Currently, however, the visits made to mental health professionals (e.g., general practitioners, nurse practitioners, physician assistants, psychiatrists, clinical psychologists, clinical social workers and/ or clinical nurse specialists) after that initial visit, is covered by Medicare at 60%, leaving the beneficiary (or their Medigap plan) covering the other 40% of the services.  This coverage will change in the coming years; in an attempt to create mental-health parity, Medicare will cover 65% in 2013 and then 80% for 2014 and beyond. 

For more information, visit www.medicare.gov