Medicare and Outpatient Mental Health Care Coverage
Medicare Part B (Medical Insurance) helps to cover outpatient mental health care and visits with these types of health professionals (deductibles and coinsurance may apply):
- A psychiatrist or other doctor
- Clinical psychologist
- Clinical social worker
- Clinical nurse specialist
- Nurse practitioner
- Physician assistant
Part B covers outpatient mental health services, including services that are usually provided outside a hospital (like in a clinic, doctor’s office, or therapist’s office) and services provided in a hospital’s outpatient department. Part B also covers outpatient mental health services for the treatment of inappropriate alcohol and drug use. Part B helps pay for these covered outpatient services (deductibles and coinsurance may apply):
- 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. The Patient pays nothing for your yearly depression screening if your doctor or health care provider accepts the assignment.
- Individual and group psychotherapy with doctors or certain other licensed professionals allowed by the state.
- Family counseling, if the main purpose is to help with the treatment.
- Psychiatric evaluation.
- Medication management.
- Certain prescription drugs that aren’t usually “self-administered” like some injections.
- Diagnostic tests.
- Partial hospitalization.
- A one-time “Welcome to Medicare” preventive visit. This visit includes a review of the Patient’s potential risk factors for depression. The patient pays nothing for this visit if your doctor or other health care provider accepts the assignment.
- A yearly “Wellness” visit. Medicare covers a yearly “Wellness” visit once every 12 months (if the patient had Part B for longer than 12 months). This is a good time to talk to doctors or other health care providers about changes in mental health so doctors can evaluate patient changes year to year. Patients pay nothing for their yearly “Wellness” visit if the doctor or other health care provider accepts the assignment.
Related Article: MEDICARE PART D AND MENTAL HEALTH
How much Patient will Pay
In general, after the Patient pays yearly Part B deductible for visits to a doctor or other health care provider to diagnose or treat the condition, they pay 20% of the Medicare-approved amount if the health care provider accepts the assignment.
If Patient gets their services in a hospital outpatient clinic or hospital outpatient department, they may have to pay an additional copayment or coinsurance amount to the hospital.
Medicare may Cover Partial Hospitalization
Part B covers partial hospitalization in some cases. Partial hospitalization is a structured program of outpatient psychiatric services provided to patients as an alternative to inpatient psychiatric care. It’s more intense than the care they get in a doctor’s or therapist’s office. This type of treatment is provided during the day and doesn’t require an overnight stay.
Medicare helps cover partial hospitalization services when they’re provided through a hospital outpatient department or community mental health center. As part of the Patient’s partial hospitalization program, Medicare may cover occupational therapy that’s part of the Patient’s mental health treatment and/or individual patient training and education about your condition.
For Medicare to cover a partial hospitalization program, the Patient must meet certain requirements, and the doctor must certify that the Patient would otherwise need inpatient treatment.
The patient pays a percentage of the Medicare-approved amount for each service they get from a doctor or certain other qualified mental health professionals if health care professional accepts an assignment. The patient pays coinsurance for each day of partial hospitalization services provided in a hospital outpatient setting or community mental health center.
What Original Medicare doesn’t cover
- Transportation to or from mental health care services.
- Support groups that bring people together to talk and socialize. (Note: This is different from group psychotherapy, which is covered.)
- Testing or training for job skills that aren’t part of the Patient’s mental health treatment.
It is really crucial to understand your patients’ insurance coverage. What is their co-pay, co-insurance; how many sessions are allowed, group session allowed or not. It will help you to increase your reimbursement as there are fewer chances of denials. Or you can simply get associated with medical billing companies like E2E Medical Billing Services where our billers are up to date on the Patient’s insurance coverage. To know more about our services call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com