Medicare Advantage plans cover a wide array of mental health services. Compared to Original Medicare, some Medicare Advantage plans offer more inpatient services, outpatient mental health and substance abuse recovery services, and prescription drug coverage. Participating providers can include individual therapists, community mental health centers, and hospitals. 

Each Medicare Advantage plan may have different providers and levels of coverage. Here is what you need to know about Medicare Advantage mental health benefits and how to determine your best coverage options.

Original Medicare vs. Medicare Advantage Mental Health Benefits

Original Medicare is a public program divided into parts: Part A for hospitalization, Part B for medical care and Part D for prescription drug coverage. Part C is Medicare Advantage—private health insurance that includes Original Medicare coverage in addition to the add-ons subscribers choose. A Medicare Advantage plan may cover services not covered under Original Medicare, such as support groups for mental health and certain prescription drugs.

Original Medicare and Medicare Advantage provide one free screening for clinical depression per year. In addition, the Welcome to Medicare Visit and Annual Wellness Visit also address mental health issues, including personal and family history. 

Original Medicare covers inpatient and outpatient mental health services. However, Medicare beneficiaries must meet their Part B deductible before mental health coverage commences. If the deductible is met, the beneficiary pays their mental healthcare provider 20% of the Medicare-approved amount for the visit. 

Under Medicare Advantage, subscribers may not need to meet a deductible to receive mental health services from an in-network provider. Different tiers of mental health coverage may be available depending on the region and how many providers participate in the network. Mental health services coverage can be tailored based on the subscriber’s needs, such as individual counseling, inpatient substance abuse treatment, intensive treatments or medications. Medicare Advantage requires subscribers to utilize providers within the plan’s network, although some plans may offer out-of-network benefits for mental health services. 

Which Mental Health Services Does Medicare Cover?

Original Medicare covers a variety of mental health services, but their coverage levels vary. Covered services include:

• Individual counseling and therapy from a licensed clinician, such as a licensed clinical social worker or psychologist
• Family therapy, if deemed it would help the beneficiary’s condition
• Mental health counseling received via telehealth (until December 31, 2024 for most beneficiaries)
• Screenings for depression and alcohol misuse
• Smoking cessation counseling and programs
• Opioid use disorder treatment services
• Partial hospitalization for mental health reasons

Original Medicare does not cover the following mental health services:

• Counseling and therapy from a religious counselor
• Marriage counseling
• Grief counseling
• Medications if the beneficiary does not have Part D coverage

Mental Health Issues Among Medicare Beneficiaries

Financial barriers and coverage gaps have made it difficult for Medicare beneficiaries to access the care they need. It is estimated that one in four Medicare beneficiaries has a mental illness, but only 40-50% receive treatment. A study of more than 793,000 Medicare beneficiaries found that financial barriers like high coinsurance rates factored into why so few beneficiaries utilized behavioral health services, but use levels remained low even though Medicare improved its cost-sharing structure. Potential reasons for continued low utilization include difficulty navigating care and a lack of available providers.

Approximately 31% of Original Medicare beneficiaries and 28% of Medicare Advantage subscribers have mental illnesses, with lower-income and disabled beneficiaries having the highest incidences of mental illness. This encompasses outpatient counseling for depression and anxiety, ADHD medications, inpatient treatment for autistic burnout and other mental health services that vastly improve beneficiaries’ quality of life.

Original Medicare limits beneficiaries to 60 days of inpatient care at no cost. After 60 days, a $408 copayment per day applies then rises to $816 after the 91st day. Beneficiaries have 60 reserve days in their lifetimes, which kick in after the 91st day. They are responsible for all costs after the lifetime reserve days have been depleted. If the beneficiary is admitted to a psychiatric hospital, Medicare Part A only covers 190 days of inpatient psychiatric care during the beneficiary’s lifetime.

Medicare Advantage plans can provide enhanced accessibility to mental health services.  Cost-sharing varies by plan and can offer more favorable coverage that doesn’t place lifetime coverage limits on subscribers.

Do Mental Health Providers Accept Medicare?

Many Americans have difficulty accessing mental healthcare since many mental healthcare providers do not accept insurance. Medicare is no exception: 43% of the 28,000 providers that opted out of accepting Medicare as of 2022 are in the behavioral health sector. The patient must pay these providers out of pocket and does not get reimbursed by Medicare.

Medicare beneficiaries have a notable care gap when it comes to mental health services because so few providers accept assignments from Medicare. Medicare Advantage plans aim to close this coverage gap by offering a larger network of providers with a lower attrition rate than Original Medicare.

Medicare Advantage mental health and wellness benefits may provide more affordable alternatives to Original Medicare in helping beneficiaries get the mental health services that they need. Medicare Advantage plans may cover different types of therapies, partial and long-term hospitalization in general and psychiatric hospitals, and substance abuse recovery services with cost-sharing rates, deductibles and premiums that scale to the level of coverage. 

For more information on Medicare Advantage mental health benefits or to learn more about Baylor Scott & White Health Plan’s Medicare Advantage coverage, call 1.800.782.5068 (TTY: 711).