Does Medicare Pay for Ketamine Treatments?

Ketamine, a medication with a long history primarily as an anesthetic, has garnered increasing attention for its potential applications beyond the operating room. Individuals exploring ketamine for various medical uses often question Medicare coverage. Understanding Medicare’s framework, including its different parts and specific coverage criteria, is important when considering ketamine treatment options. This article clarifies how Medicare may cover ketamine, depending on its purpose and administration method.

Ketamine Coverage Under Traditional Medicare Parts

Original Medicare is divided into Part A (Hospital Insurance) and Part B (Medical Insurance), each covering different aspects of healthcare. Ketamine may fall under either part depending on its use and administration. Medicare Part A generally covers ketamine when it is utilized as an anesthetic during an inpatient hospital stay or at a skilled nursing facility, as part of a covered surgical procedure. After meeting the Part A deductible, which is $1,676 in 2025, beneficiaries may incur no additional costs for the first 60 days of eligible inpatient services.

Medicare Part B may cover ketamine when administered in an outpatient setting, such as a doctor’s office, emergency room, or urgent care center. This applies when ketamine is used as an anesthetic during an outpatient procedure or as a physician-administered drug. After satisfying the annual deductible, which is $257 in 2025, Medicare typically covers 80% of the Medicare-approved amount, leaving the beneficiary responsible for the remaining 20% coinsurance. Take-home prescription drugs are typically covered under Medicare Part D. However, because most forms of ketamine requiring medical supervision are administered in a clinical setting, they generally fall under Part B rather than Part D.

Ketamine for Specific Medical Conditions

The application of ketamine for different medical conditions dictates how Medicare coverage may apply. Ketamine is FDA-approved as an anesthetic and is generally covered by Medicare Part A or Part B when used during surgical procedures, depending on whether the procedure is performed in an inpatient or outpatient setting. This coverage reflects its long-standing and approved use for inducing general anesthesia.

Medicare coverage for ketamine for mental health conditions is more specific. Esketamine, marketed as Spravato, is an FDA-approved nasal spray derived from ketamine used for treatment-resistant depression (TRD) and major depressive disorder with suicidal ideation. Medicare Part B may cover esketamine if it is administered in a certified facility under direct medical supervision, due to its requirement for supervised administration and monitoring. Medicare generally does not cover other forms of ketamine, such as intravenous (IV) ketamine infusions, for off-label uses like depression, as these are not FDA-approved for such indications and are often considered investigational.

Out-of-Pocket Costs and Medicare Advantage

Beneficiaries typically incur out-of-pocket costs, which include deductibles, copayments, and coinsurance. Under Original Medicare (Parts A and B), after the annual deductible is met, a beneficiary is responsible for a coinsurance amount, which is 20% for most Part B-covered services. For instance, the 2025 Part B annual deductible is $257, and the Part A deductible for inpatient hospital stays is $1,676 per benefit period. These costs represent the beneficiary’s share of the Medicare-approved amount for covered services.

For prescription drug coverage under Part D, out-of-pocket expenses can involve monthly premiums, annual deductibles, and varying copayments or coinsurance depending on the drug’s tier and the plan’s design. In 2025, the standard Part D deductible is $590, and there is a $2,000 annual cap on out-of-pocket spending for covered drugs. Medicare Advantage plans (Part C) are offered by private insurance companies and must cover at least the same benefits as Original Medicare. However, these plans can have different cost-sharing structures, provider networks, and prior authorization requirements, meaning out-of-pocket costs for ketamine treatment can vary significantly based on the specific plan.

Confirming Coverage and Provider Discussions

Understanding Medicare coverage for ketamine treatments requires direct communication with healthcare providers and Medicare plans. Beneficiaries should discuss the proposed treatment with their healthcare provider or the facility administering the treatment to clarify what will be billed to Medicare. It is advisable to inquire about specific billing codes and to understand any associated charges.

Prior authorization is often required for specialized treatments like esketamine, and the provider can help navigate this process by providing necessary medical documentation. Beneficiaries should contact their specific Medicare plan, whether it is Original Medicare or a Medicare Advantage plan, to verify coverage details, potential costs, and any specific plan rules before receiving treatment. This proactive approach helps to avoid unexpected financial responsibilities and ensures that the desired treatment aligns with the beneficiary’s coverage.