Medicare Coverage of Outpatient Mental Healthcare
What It Is
Mental healthcare and services provided on an outpatient basis in an office, clinic, or hospital outpatient department
Medicare Part B covers outpatient mental healthcare and services in different settings and treatment structures, from a variety of providers.
Medicare Part B covers mental healthcare and services from Medicare-participating doctors (this can include individual or group psychotherapy), clinical psychologists, clinical social workers, nurse practitioners or nurse specialists, and other state-licensed medical health workers. Medicare Part B covers mental healthcare and services in an office, health clinic, mental health clinic, or hospital outpatient department. Medicare Part B doesn't cover medications prescribed as part of mental healthcare.
Intensive outpatient care ("partial hospitalization"). Medicare Part B also covers a structured program of psychiatric treatment called "partial hospitalization," in which outpatient treatment is more frequent and intensive than with usual office visits to a doctor or psychologist. In order to qualify for Medicare Part B coverage of partial hospitalization treatment, the patient's doctor must certify that the patient would otherwise need to be hospitalized.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B plans.) To find out whether your plan provides extra coverage or requires different co-payments for outpatient mental healthcare, contact the plan directly.
If you have a Medicare Part D prescription drug plan: A Medicare Part D prescription drug plan can cover some medications prescribed for outpatient mental healthcare. To find out whether your plan covers a specific medication, and what the co-payments are, contact the plan directly.
What Medicare Pays
Medicare Part B pays 80 percent of the Medicare-approved amount for diagnosis and monitoring by a psychiatrist or other medical doctor.
Medicare Part B pays 50 percent of the Medicare-approved amount for mental health therapy and most other outpatient mental healthcare and services. If services are provided by a clinic or hospital outpatient department, the patient may also be personally responsible for a co-payment.
For partial hospitalization program services, Medicare Part B pays the entire Medicare-approved amount, except for a daily co-payment for which the patient is responsible. There may also be an additional co-payment if program services are received at a clinic or hospital outpatient department.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.
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