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Medicare Coverage of Outpatient Mental Healthcare

By Caring.com Staff

What It Is

Mental healthcare and services provided on an outpatient basis in an office, clinic, or hospital outpatient department

What's Covered

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.