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Original Medicare, mental health and substance use disorders

Original Medicare, mental health and substance use disorders

Mental health concerns and substance use disorders have spiked during the pandemic. Congress and the Biden administration have taken a number of steps to address these concerns for Medicare beneficiaries, including expanding Medicare provider types paying for these services, as well as extending telehealth flexibilities. 

Here’s what some of our most vulnerable members of society need to know.

Covered services, their costs, and the providers that can render them
Let’s start with the good news: There are a number of services that Medicare will cover at 100%, so long as the provider accepts assignment – that is, the provider accepts Medicare’s fee schedule as full payment for these services.

These no-cost services include:

  • “Welcome to Medicare” visit, when scheduled within the first 12 months of having Part B
  • Annual wellness visits
  • Yearly depression screenings
  • Alcohol misuse screenings
  • Tobacco cessation counseling
  • Opioid use disorder treatment, so long as the service is received from a Medicare-enrolled opioid treatment program

For inpatient hospitalization at a psychiatric hospital, beneficiaries are subject to their Part A deductible and copays for each benefit . Individual and group therapy, family counseling, psychiatric evaluations, medication management, Part B drugs and telehealth services are all subject to the Part B deductible and 20% coinsurance

Prior to 2023, Medicare provided coverage and reimbursement only when beneficiaries sought mental health or substance use disorder treatments from psychiatrists, clinical psychologists, clinical nurse specialists, nurse practitioners and physician assistants. Beginning this year, Medicare will now reimburse supervising or billing providers for services rendered by licensed professional counselors, marriage therapists and family therapists. In 2024, Medicare will directly reimburse these provider types.

Expanded telehealth coverage
Prior to the pandemic, telehealth was only covered for beneficiaries in rural areas – and even then, only when the beneficiary was seated in an actual healthcare setting, like a clinic or doctor’s office. One exception to this rule was for individuals diagnosed with a substance use disorder – visits to treat those disorders or co-occurring mental health disorders were covered, without any geographic boundaries.

Through at least the end of 2024, beneficiaries in any area may now access telehealth services, and can receive those services in the comfort of their own home. This expansion has had a marked impact on behavioral health: during the first year of the pandemic, telehealth accounted for 43% of all behavioral health services.

In 2025, these requirements will change slightly. The Consolidated Appropriations Act of 2023 will require that beneficiaries visit a physician’s office within six months prior to the initial telehealth service. From then on, there must be at least one in-person visit every 12 months. We should note, though, that these in-person requirements only apply to treatment of mental health disorders; substance use disorders are addressed in other laws, and will not have the same in-person requirements.

Final thoughts
Legislative and rule changes have granted Medicare beneficiaries even more access points for mental health and substance use disorder care. While health insurance agents are not healthcare providers, knowing what services are covered can make a huge difference for your clients in need. 

Want to know how these rule changes affect Medicare Advantage plans? Read part two.