So much of the media’s focus these days is how prevalent mental illness is among the under 25 crowd. However, America’s youth do not have a strong hold on mental illness. In fact, mental illness affects millions of senior Americans, with depression and anxiety being two of the most common diagnoses. Nearly 30% of Medicare recipients have some type of mental health condition, yet there’s no denying Medicare’s coverage of mental health services falls far short of its physical health coverage counterpart.
With so much of the American population approaching 65, the Medicare population is rapidly growing. This makes the gaps and limitations in Medicare’s mental health benefits a critically important issue. Seniors suffer when they cannot access adequate treatment and support for mental illnesses that impact their wellbeing and quality of life. That’s why mental health advocacy groups argue that it is past time for Medicare to expand its psychiatric services and work towards mental health parity.
This blog will examine how original Medicare. Parts A and B currently cover – and fail to cover – services for common mental illnesses like depression and anxiety. It will analyze the specific shortfalls, from limits on therapy sessions to lack of coverage for medications and outpatient programs. Finally, recommendations will be provided for how Medicare could improve its mental health benefits to better serve the nearly 60 million older adults who depend on it. Comprehensive mental health coverage in Medicare is vital for supporting our rapidly growing senior population.
Medicare Part A (Hospital Insurance)
Medicare Part A covers inpatient mental health care received in a dedicated psychiatric hospital. This includes room and board, nursing care, counseling, medical testing, prescription drugs administered during the hospital stay, and all other medically necessary services associated with the inpatient psychiatric admission.
To qualify for Part A’s mental health coverage, the hospital stay must be ordered by a physician who certifies that inpatient treatment is required. Stays may be covered if a mental illness is putting the patient at risk of harming themselves or others. Coverage can also apply if a mental health condition significantly interferes with a person’s ability to complete activities of daily living and function independently.
However, there are strict limits on the number of covered hospital days. In 2023, Medicare covers up to 190 days of care in a freestanding psychiatric hospital per benefit period. This limit applies specifically to mental health admissions, separate from physical health hospital stays. Patients are responsible for a Part A deductible when first admitted, which was $1,600 in 2022. Additionally, copays start on day 61 of a psychiatric stay, reaching $400 per day by day 90.
Mental health advocates argue these coverage limitations can cut short needed inpatient treatment. They recommend removing the 190-day cap and instead determining coverage based on medical necessity. This would allow doctors more flexibility in treating seniors with severe depression, schizophrenia, bipolar disorder, and other illnesses requiring longer-term psychiatric care. More comprehensive Part A coverage could help prevent seniors from decompensating and needing readmission after being discharged too soon.
Medicare Part B (Medical Insurance)
For outpatient mental health care, Medicare Part B provides coverage for visits to psychiatrists, psychologists, licensed clinical social workers, nurse practitioners, and other Medicare-approved mental health professionals.
These therapy sessions may take place in a doctor’s office, clinic, or via telehealth with a provider licensed in the patient’s state. Part B covers diagnosis, counseling, and treatment for mental illnesses like depression, anxiety, bipolar disorder, PTSD, and more.
In addition to individual psychotherapy, Part B also covers group mental health counseling sessions. Family therapy is covered as well if deemed medically necessary. Other Part B-covered services include mental health testing like psychological and neuropsychological evaluations.
For medications, Part B covers injectable psychiatric drugs that are administered in a medical setting. However, it does not cover prescriptions filled at the pharmacy. Those must be obtained through a separate Medicare Part D prescription drug plan.
After meeting the annual Part B deductible ($226 in 2022), patients pay 20% coinsurance for mental health services. However, coverage is restricted to 36 sessions per year in most cases. Additional visits may be covered if deemed medically reasonable and necessary. Still, critics argue the visit limitations remain a barrier to adequate mental health treatment, especially for seniors with chronic psychiatric issues.
While Medicare covers inpatient and outpatient mental health services, there are some significant limitations:
– No coverage for care at residential treatment facilities, partial hospitalization programs, or intensive outpatient therapy.
– No coverage for treatment of mental illnesses if a beneficiary is admitted to a general hospital psychiatric unit.
– Strict limits on the number of mental health sessions per year. In 2023, Medicare covers up to 36 sessions for most outpatient psychotherapy.
– Higher copays and coinsurance for mental health services than physical health services under Original Medicare.
– No coverage for prescription psychiatric medications. Those must be covered separately under Part D plans.
Recommendations for Improving Coverage
Advocates have argued for years that Medicare’s mental health benefits should be more aligned with physical health services. Here are some recommendations for improving Medicare’s mental health coverage:
– Remove limits on the number of covered therapy sessions. Instead determine coverage based on medical necessity.
– Extend coverage to intensive outpatient and partial hospitalization programs for mental illnesses.
– Cover residential/inpatient treatment for major depression, schizophrenia, and other serious conditions.
– Implement copay parity, so coinsurance is the same for mental health and physical health services.
– Add a prescription drug benefit to Part B to help cover psychiatric medications for beneficiaries without Part D.
– Cover annual depression screenings for early intervention and treatment.
Medicare’s mental health benefits have significant gaps in coverage that can prevent seniors from getting the necessary treatment for depression, anxiety, and other mental illnesses. Both Part A and Part B contain limits on services that arbitrarily restrict care based on “one size fits all” policies rather than medical necessity.
To better serve the growing mental health needs of America’s senior population, advocates recommend modernizing Medicare to cover mental illness on par with physical illness. This includes removing limits on therapy sessions, implementing mental health parity for coinsurance rates, and expanding coverage to include residential treatment, partial hospitalization, and intensive outpatient care. Prescription drug coverage under Part B could also help seniors afford psychiatric medications.
Comprehensive mental health coverage has the potential to greatly increase access to care while reducing costs over the long-term. With earlier intervention and consistent treatment, seniors are more likely to maintain stability and avoid repeated crises leading to expensive emergency and inpatient services. As Medicare continues to evolve, expanding its mental health benefits must be a top priority. Seniors experiencing depression, anxiety and other psychiatric issues deserve nothing less than full support for their mental wellbeing.