Medicare Limits on Mental Health Benefits - dummies

Medicare Limits on Mental Health Benefits

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Like many other insurance plans, Medicare treats care for mental health disorders differently from other health problems. This kind of discrimination is less common than it used to be in Medicare, but some limits are still placed on mental health benefits, as described here.

Outpatient psychiatric services

In the past, traditional Medicare charged more than twice as much for seeing a mental health professional as an outpatient than for seeing any other kind of doctor — co-pays of 50 percent of the cost of a visit rather than 20 percent.

But since 2010, under a law passed in 2008, those co-pay costs have gradually come down. So in 2013, you pay 35 percent of the Medicare-approved cost for an outpatient psychiatric visit. And in 2014 and subsequent years, you pay the standard 20 percent, and Medicare pays the rest.

If you have Medigap insurance, these co-pays are covered. If you’re in a Medicare Advantage plan, you pay what your plan requires.

Psychiatric care in a hospital

The 2008 health care law didn’t change a discriminatory situation in which Medicare patients are limited to 190 days over their lifetime for receiving inpatient treatment in psychiatric hospitals — those that specialize in mental health conditions.

Yet Medicare places no such limit on care in general hospitals. So any days you spend in a non-psychiatric hospital — even if you’re being treated for a mental health condition — don’t count toward the 190-day lifetime limit.

Whether you receive mental health care in a psychiatric or a general hospital, the Part A hospital deductible and co-pays are the same as those for other medical conditions.

In some circumstances, Medicare covers partial hospitalization, which means receiving treatment at a hospital’s outpatient department or clinic or at a community mental health center during the day, but not spending the night there. Your costs for this type of service vary according to the treatment provided, but under Medicare rules it can’t be more than 40 percent of the Medicare-approved amount.

Mental health benefits in Medicare Advantage plans

Because mental health benefits may vary among Medicare Advantage plans, look at the evidence of coverage documents for your plan. But most plans stick to the same limit of 190 lifetime days for inpatient care in a psychiatric hospital.