How prevalent are mental health issues among Medicare beneficiaries?
About one in four Medicare beneficiaries live with mental illness — conditions such as depression, anxiety, schizophrenia, and bipolar disorder — but only 40 percent to 50 percent receive treatment.1 The prevalence of mental illness is about equal among beneficiaries enrolled in traditional Medicare (31%) and those in Medicare Advantage plans (28%), although variation in data sources and measurement make comparisons difficult.2
Mental illness is experienced most by those beneficiaries under age 65 who qualify for Medicare via disability, as well as by low-income beneficiaries dually eligible for Medicare and Medicaid.3 It is also more pervasive in beneficiaries from American Indian/Alaska Native and Hispanic communities relative to other racial and ethnic groups.4
Which mental health services does Medicare cover?
Medicare covers both outpatient and inpatient services as well as prescription drugs to treat mental illness.5 Traditional Medicare and Medicare Advantage plans generally follow the same coverage rules, and some also cover additional services, like grief counseling, or offer other tailored benefits through special needs plans catering to beneficiaries with mental illness.6
Inpatient services. Medicare Part A covers inpatient mental health services in both general hospitals and psychiatric hospitals, but the latter is limited to 190 total days per beneficiary across their lifetime. Traditional Medicare beneficiaries pay a deductible and coinsurance for each benefit period, which, for hospital services, begins on the day of admission and ends after a beneficiary has had no inpatient care for 60 consecutive days. Cost-sharing requirements vary across plans for Medicare Advantage enrollees.
Outpatient services. Medicare Part B covers outpatient mental health services delivered by psychiatrists or other physicians, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician assistants. The services covered include standard services like psychiatric evaluation, individual and group therapy, and medication management. After paying their annual deductible, traditional Medicare beneficiaries pay 20 percent of the Medicare-approved amount for covered services. As with inpatient services, cost-sharing requirements vary across Medicare Advantage plans.
Medication. For traditional Medicare beneficiaries, mental health medications are covered by Medicare Part D. Beneficiaries in a Medicare Advantage plan also may have a Part D prescription drug plan or another drug plan that follows Part D rules. All Medicare drug plans are required to cover antidepressant, anticonvulsant, and antipsychotic medications, as well as a wide range of other psychotropic medications like anti-anxiety drugs. Specific medications covered and out-of-pocket costs vary by drug plan.