Does Medicare Cover Inpatient Mental Health?

Medicare, the federal health insurance program, provides healthcare coverage for older adults and individuals with specific disabilities. Medicare covers inpatient mental health services, though the specifics depend on the facility type and duration of care.

Medicare Part A Coverage for Inpatient Mental Health

Medicare Part A, Hospital Insurance, covers inpatient mental health care in general hospitals or freestanding psychiatric hospitals. This coverage includes room and board, nursing care, meals, necessary medications, and other services integral to inpatient treatment.

A distinction exists between care in a general hospital and a freestanding psychiatric hospital. While there is no lifetime limit on the number of benefit periods for mental health care received in a general hospital, a 190-day lifetime limit applies to care in a freestanding psychiatric hospital. This means that after a beneficiary has used 190 days of inpatient mental health services in a freestanding psychiatric hospital over their lifetime, Medicare Part A will no longer cover additional days in such a facility. This limitation does not apply if mental health care is provided within a psychiatric unit of an acute care or critical access hospital.

For Medicare to cover inpatient mental health care, the services must be medically necessary and ordered by a physician. Medical necessity requires that the patient needs intensive, comprehensive treatment, including 24-hour medical supervision and coordination for a mental disorder. The physician must certify at the time of admission, or as soon as practicable thereafter, that the inpatient hospitalization is reasonable and necessary for treatment expected to improve the patient’s condition or for diagnostic study.

Costs Associated with Medicare Part A Inpatient Mental Health Coverage

Financial obligations for inpatient mental health care under Medicare Part A involve a “benefit period.” A benefit period begins the day a person is admitted as an inpatient to a hospital or skilled nursing facility and ends after they have been out of the hospital or skilled nursing facility for 60 consecutive days. A new benefit period starts if a patient is readmitted after 60 days, which means a new deductible may apply.

For each benefit period in 2025, beneficiaries are responsible for a Part A deductible of $1,676. After this deductible is met, Medicare covers the full cost for the first 60 days of inpatient care within that benefit period. For stays extending beyond 60 days, a daily coinsurance applies.

For days 61 through 90 of an inpatient stay in 2025, the daily coinsurance amount is $419. If an inpatient stay extends beyond 90 days, beneficiaries can use “lifetime reserve days,” of which they have 60 over their entire lifetime. For each lifetime reserve day used in 2025, the daily coinsurance is $838. Once all 60 lifetime reserve days are exhausted, Medicare pays nothing for additional inpatient days, making the beneficiary responsible for all costs.

How Other Medicare Parts Relate to Inpatient Mental Health

Other components of Medicare also interact with mental health care. Medicare Part B, which covers Medical Insurance, primarily focuses on outpatient mental health services. This includes services like therapy sessions, doctor visits, and partial hospitalization programs, which offer intensive treatment without requiring an overnight stay. Part B does not cover inpatient room and board, as those facility costs fall under Part A. However, Part B may cover some physician fees incurred during an inpatient stay, with beneficiaries typically paying 20% of the Medicare-approved amount after meeting the Part B deductible.

Medicare Part C, Medicare Advantage Plans, provides an alternative way to receive Medicare benefits. These plans, offered by private companies approved by Medicare, are required to cover at least all the services that Original Medicare (Parts A and B) covers, including inpatient mental health care. However, Medicare Advantage plans often have different cost-sharing structures, such as varying copayments and deductibles, and may operate with specific provider networks and require prior authorizations for services.

Medicare Supplement Insurance, or Medigap, consists of private policies that help cover out-of-pocket costs associated with Original Medicare. These policies can help pay for expenses such as Part A deductibles and coinsurance amounts incurred during inpatient stays, including those for mental health care. It is important to note that Medigap policies only work in conjunction with Original Medicare and cannot be used if an individual is enrolled in a Medicare Advantage plan.

Navigating Inpatient Mental Health Care with Medicare

Accessing inpatient mental health care through Medicare requires specific procedures. A doctor’s order is necessary for inpatient admission, confirming the medical necessity of the stay. The facility must be Medicare-approved, whether it is a general hospital with a psychiatric unit or a freestanding psychiatric hospital.

The initial psychiatric evaluation should occur within 24 hours of admission to establish medical necessity. If questions arise about coverage or if a claim is denied, beneficiaries have rights to appeal the decision. They can contact the hospital’s patient advocate, call Medicare directly, or pursue formal appeal processes.

A crucial distinction exists between inpatient status and observation status, as Medicare Part A only covers true inpatient stays for mental health services. Observation status, often used while a doctor decides whether a patient needs to be admitted as an inpatient, is generally covered under Medicare Part B, impacting the patient’s out-of-pocket costs and benefits significantly. Understanding this difference is vital as it affects Medicare payment and beneficiary financial liability.