A Guide to Mental Wellness in Older
Age: Recognizing and Overcoming Depression
Paying for Mental Health Services under Medicare
vast majority of older Americans have Medicare as their
primary health insurer, however, the system
is complicated and payment for mental health services
are treated differently under Medicare than payment
for other health care services.
Medicare is made up
of two parts:
-Medicare Part A pays for hospital services.
If you are hospitalized for your depression, Medicare
pay as it would for any other hospitalization. However,
if you are in a specialty psychiatric facility, Medicare Part A will pay for
up to 190 days of inpatient care (in a Medicare-certified psychiatric hospital).
If you are hospitalized in a psychiatric facility for over 190 days, your secondary
insurer must pay or you are responsible for the expenses.
-Medicare Part B pays
for outpatient mental health services—such as
services that are provided outside a hospital or do
not require an overnight stay. These
services include physician services, individual and group therapy, and laboratory
tests. Unlike for other health services, Medicare Part B will only pay 50 percent
of your outpatient expenses after you have paid your yearly deductible. The other
complicating factor is that Medicare is not consistent for which mental health
services it will reimburse 80 percent of the expenses and for which mental health
services it will reimburse 50 percent of the expenses. For example, although
it is a Federal regulation that Medicare reimburse at the 80 percent rate for
the diagnosis or medical management of Alzheimer’s
disease, that is not always the case. Medicare is also supposed to reimburse
at 80 percent if you see your physician for what is called medication management—brief
follow-up appointments to ensure that your medication is working properly. Again,
areas in the country Medicare will pay 80 percent of those costs; in other areas,
Medicare will pay only 50 percent of those costs.
Many people have a secondary
insurance plan in addition to Medicare, commonly called Medigap.
Medigap insurance policies are required to cover mental health
services not covered by Medicare. However, some supplemental plans offered
to retirees by their former employers are not required to meet this standard.
It is always best to review your policy before you begin treatment so you are
clear on what expenses Medicare will cover,
what expenses your health insurance will cover, and
what expenses you will be responsible
for out of your own pocket. You should feel free to discuss these issues with
If you are dependent upon Medicare as your primary
health insurance, ask your doctor whether they accept
Medicare as payment.
Some physicians have opted
not to accept Medicare health insurance due to the complications of the law.
for mental health services under Medicare is discriminatory.
There should be no difference between payment for services for diabetes or
and for depression. Many organizations are working to change this unfair
Prescription Drug Benefits Under Medicare
In 2003, the U.S. Congress passed
a bill that will permit Medicare to pay for prescription drugs. The new law
is complicated and does not become effective
until 2006, however, for some people, the new law will help pay for medications
that can be very expensive. The newer antidepressants, the SSRIs, cost $50
to $90 per month; older antidepressants are a little
less expensive. The Centers for
Medicare and Medicaid Services has a section on its website that will guide
adults to programs in their area that help cover the costs of expensive medications.
Until the new benefit becomes effective, Medicare
provides information on public and private programs
that offer Medicare-approved drug discount cards and
other assistance in obtaining prescription drugs. Information
is also available about a program offered by pharmaceutical
companies called Together Rx, which can help with costs
for some older adults.
1-800-MEDICARE or 1-800-633-4227
In 2006, the new Medicare prescription drug benefit
will become effective. Premiums for this new program
are estimated to be $35 per month or $420 per
there will be a $250 annual deductible. This new benefit will pay 75 percent
of your drug
costs until your total prescription drug costs reach $2,250. After you reach
$2,250 in drug expenses in a given year, your coverage stops and you have
to pay for the next $2,850 in medication expenses. The prescription drug
begins again after your medication expenses exceed $5,000 in the year. For
many older adults, this drug coverage may be of some assistance, but they
have to pay large out-of-pocket amounts for their prescription drugs. For
low-income seniors (individuals whose yearly income is less than $13,000
per year), there
will be some additional assistance to cover the cost of your medicines.
new Medicare prescription drug program is required
to cover drugs in all classes, but is not required
to cover every drug in a drug class. For
the new Medicare drug program will cover antidepressants, but it may not
cover all antidepressants. This may be a problem if there is one antidepressant
you tolerate better or is more effective than another antidepressant. It
is possible that the Medicare drug program will not cover the antidepressant
If you want to learn more about this new law, or if
you want to see what type of Medicare coverage you
can expect under
the new Medicare drug law,
the Families USA website at www.familiesusa.org.
Families USA is a national nonprofit,
non-partisan organization dedicated to high-quality, affordable health
care for all Americans.
A Guide to Mental Wellness in Older Age: Recognizing
© Geriatric Mental Health Foundation 2004
7910 Woodmont Avenue, Suite 1050
Bethesda, Maryland 20814
was provided by Lissy F. Jarvik, M.D., Professor Emerita of Psychiatry
and Biobehavioral Sciences, University of California-Los
Angeles, School of Medicine; Susan Lieff, M.D., M.Ed., Assistant Professor,
of Psychiatry, University of Toronto; and Stephen J. Bartels, M.D.,
Associate Professor of Psychiatry, Dartmouth Medical School.
Mental Health Foundation grants permission to print,
photocopy, and distribute this material. Please cite
the Foundation, including the
address, phone and website.