Medicare

Overview of Medicare

Medicare is the federal health insurance for people in the United States that are 65 or older. Medicare is also a federal health insurance for certain younger people with disabilities and individuals with End-Stage Renal disease (permanent kidney failure requiring dialysis or a transplant, sometimes referred to as ESRD). For many individuals over the age 65, they may experience declining health and the challenges of managing multiple diseases. This can put people at risk for mental health conditions like depression or anxiety.

Medicare covers many benefits to care for individuals mental well-being, including psychological counseling, preventive screenings, and outpatient treatment programs.

Original Medicare

Original medicare has 2 parts; Part A (hospital insurance) and Part B (medical insurance). The individual has the choice of doctors, hospitals, and other providers that are accepted by Medicare. In 2019, the standard Part B premium amount is $135.50 (or higher depending on the individuals income). Generally, a person would pay a deductible and coinsurance for Part A and Part B services. If an individual chooses to buy a Medicare Supplement Insurance (Medigap) policy, the Medigap policy may pay some of these costs.

Medicare Advantage (MA) Plan

Medicare Advantage, which can also be called Part C, which includes Part A (hospital insurance) and Part B (medical insurance). The individuals can choose from private insurance companies approved by Medicare. In 2019, the standard Part B premium amount is $135.50 (or higher depending on your income). Individuals usually pay a monthly premium for the MA Plan (in addition to a monthly Part B premium). An individual may pay a copayment or coinsurance for covered services.

Many MA plans offer vision, hearing, and dental coverage. Costs, extra coverage, and rules vary by plan. Plans have a yearly limit on the out-of-pocket costs. Once you reach a certain limit, they pay nothing for covered services for the rest of the year. Out-of-pocket costs may be lower in an MA plan.

Part A

Medicare Part A (Hospital Insurance) covers mental health care services an individual can get in a hospital that require them to be admitted as an inpatient. An individual can get these services either in a general hospital or a psychiatric hospital that only cares for people with mental health conditions. If an individual is in a psychiatric hospital (instead of a general hospital), Part A only pays for up to 190 days of inpatient psychiatric hospital services during an individual’s lifetime. Part A covers these services:

• Inpatient care in a hospital
• Skilled nursing facility care
• Inpatient care in a skilled nursing facility (not custodial or long-term care)
• Hospice care
• Home health care

Medicare Part A does NOT cover:

• Private duty nursing
• A phone or television in the provided room
• Personal items, like toothpaste, socks, or razors
• A private room, unless medically necessary

Part B

Medicare Part B (Medical Insurance) helps pay for these covered outpatient mental health services:

• One depression screening per year. The screening must be done in a primary care doctor’s office or primary care clinic that can provide follow-up treatment and referrals.
• Individual and group psychotherapy with doctors or certain other licensed professionals allowed by the state where an individual can get the services.
• Family counseling, if the main purpose is to help with treatment.
• Testing to find out if an individual is getting the services they need and if current treatment is helping.
• Psychiatric evaluation.
• Medication management.
• Certain prescription drugs that aren’t usually “self administered” (drugs normally taken without supervision), like some injections.
• Diagnostic tests.
• Partial hospitalization.
• A one-time “Welcome to Medicare” preventive visit. This visit includes a review of possible risk factors for depression.
• A yearly “Wellness” visit. Talk to a doctor or other health care provider about changes in mental health. They can evaluate changes year to year.
• Part B also covers outpatient mental health services for treatment of inappropriate alcohol and drug use.

Part B covers mental health services and visits with these types of health professionals: 

• Psychiatrist or other doctor
• Clinical psychologist
• Clinical social worker
• Clinical nurse specialist
• Nurse practitioner
• Physician assistant

*Medicare only covers the visits when they’re provided by a health care provider who accepts assignment.

Part B covers outpatient mental health services, including services that are usually provided outside a hospital, like in these settings:

• A doctor’s or other health care provider’s office
• A hospital outpatient department
• A community mental health center

Medicare Part B Preventive and Screening coverage

• Abdominal aortic aneurysm screening
• Alcohol misuse screenings & counseling
• Bone mass measurements (bone density)
• Cardiovascular disease screenings
• Cardiovascular disease (behavioral therapy)
• Cervical & vaginal cancer screening
• Colorectal cancer screenings
• Multi-target stool DNA tests
• Screening barium enemas
• Screening colonoscopies
• Screening fecal occult blood tests
• Screening flexible sigmoidoscopies
• Depression screenings
• Diabetes screenings
• Diabetes self-management training 
• Glaucoma tests
• Hepatitis B Virus (HBV) infection screening 
• Hepatitis C screening test
• HIV screening
• Lung cancer screening
• Mammograms (screening)
• Nutrition therapy services
• Obesity screenings & counseling
• One-time “Welcome to Medicare” preventive visit
• Prostate cancer screenings
• Sexually transmitted infections screening & counseling
• Shots:
• Flu shots
• Hepatitis B shots
• Pneumococcal shots
• Tobacco use cessation counseling
• Yearly “Wellness” visit

Medicare prescription drug coverage

Medicare Part D covers prescription drug benefits you may need for treatment of various conditions. Original Medicare, Part A and Part B, doesn’t include drug coverage, although Medicare Part B covers some medications that can’t be self-administered, such as drugs given by injection. For other prescription coverage, however, beneficiaries with Original Medicare must enroll in a separate Medicare Part D prescription drug plan. Medicare Advantage enrollees can get drug coverage through a Medicare Advantage Prescription Drug plan, which includes Medicare Part A, Part B, and Part D benefits under a single plan.

Medicare Part A and B do NOT Cover

Medicare does not cover everything. If other services are needed that are not covered, individuals may have to pay for them through other insurance or out of pocket.

• Long-term care (also called custodial care)
• Most dental care
• Eye exams related to prescribing glasses
• Dentures
• Cosmetic surgery  
• Acupuncture  
• Hearing aids and exams for fitting them
• Routine foot care

References and Additional Resources

• https://medicare.com/
• https://www.medicare.gov/your-medicare-costs
• https://www.ssa.gov/benefits/medicare/
• https://www.cms.gov/medicare/medicare.html