Key Takeaways

• Medicare now covers more mental health services and providers in 2025, but there are new usage rules that can affect whether your therapy is covered or denied.

• Missing required in-person check-ins, not using Medicare-approved therapists, or skipping enrollment steps could jeopardize your benefits.

Expanded Mental Health Coverage Isn’t Automatic

Medicare has significantly expanded mental health benefits in 2025. However, that doesn’t mean everything is automatically covered. You must meet specific criteria and follow strict procedures to ensure your therapy sessions, whether virtual or in-person, are reimbursed.

Here are the key components of Medicare mental health coverage you should understand:

• Part A covers inpatient mental health treatment, such as hospital stays.

• Part B covers outpatient care, including individual therapy, group therapy, psychiatric evaluations, and partial hospitalization.

• Part D helps with medications prescribed for mental health conditions.

• Medicare Advantage (Part C) plans must offer at least the same mental health benefits as Original Medicare, though rules for access may differ.

Each part plays a role in mental health coverage, but knowing the rules of access and compliance for Part B is especially critical if you regularly attend therapy.

New Providers Are Covered, But With Limits

As of January 1, 2024, Medicare began covering services from licensed mental health counselors (MHCs) and marriage and family therapists (LMFTs). This change continues in 2025 and offers broader access to care. However, not every counselor is automatically eligible to bill Medicare.

To qualify for Medicare reimbursement, the provider must:

• Be licensed in your state

• Be enrolled as a Medicare provider

• Bill Medicare directly for covered services

You must confirm that your provider is enrolled in Medicare. Using a therapist who accepts cash or does not submit Medicare claims could mean you pay entirely out-of-pocket.

Telehealth Is Still Covered, But There’s a Catch

Medicare still covers mental health services delivered via telehealth in 2025. You can receive therapy sessions from home through video or audio calls. But there is now a rule you cannot ignore:

• In-person visits are required at least once every 12 months.

This in-person check-in must be with the same provider who is offering telehealth services. If you miss this deadline, you risk losing Medicare coverage for subsequent virtual visits.

Exceptions apply in rare cases, such as when travel or disability makes in-person visits impossible. However, these must be properly documented and approved by Medicare.

Inpatient Mental Health Days Are Capped

Under Medicare Part A, you are covered for inpatient psychiatric care in a general or psychiatric hospital. But there’s a little-known rule:

• You are limited to 190 days of inpatient care in a psychiatric hospital over your lifetime.

After exhausting those 190 days, any additional inpatient psychiatric care must be provided in a general hospital to be covered. These limits can affect your treatment planning, especially if you have a long-term mental health condition requiring periodic hospitalization.

Costs You’re Still Responsible For

Medicare pays a significant portion of your mental health services, but you are still responsible for some out-of-pocket costs. As of 2025:

• Part B deductible is $257

• After the deductible, you pay 20% coinsurance for outpatient mental health services

• For inpatient stays, Part A has a deductible of $1,676 per benefit period

• Skilled nursing facility care for mental health recovery may require coinsurance starting on day 21

Some Medicare Advantage plans offer lower copayments, but you must stay within the plan’s provider network and follow its rules. Original Medicare allows more provider flexibility but leaves you with more direct costs unless you have Medigap.

Partial Hospitalization and Intensive Outpatient Programs

If you need more care than standard outpatient therapy but do not require full hospitalization, Medicare may cover:

• Partial Hospitalization Programs (PHPs): A structured program usually offered through hospitals or mental health centers, requiring multiple hours per day, several days per week.

• Intensive Outpatient Programs (IOPs): Newly covered under Medicare starting in 2024, and continuing in 2025. These programs offer less intensity than PHPs but more than weekly therapy sessions.

Medicare requires that both PHPs and IOPs be medically necessary and provided by facilities that accept Medicare.

Medication Coverage Under Part D

Mental health medications, including antidepressants, antipsychotics, and mood stabilizers, are covered under Medicare Part D. In 2025, some key changes affect your drug costs:

• The out-of-pocket cap is now $2,000 annually under Part D.

• Insulin costs remain capped at $35 per month for covered prescriptions.

Make sure your plan’s formulary includes your medications. If not, your prescriber may need to file an exception request. You can also switch plans during the Annual Enrollment Period (October 15 to December 7) if your needs change.

Getting a Referral Isn’t Always Required, But…

With Original Medicare, you generally do not need a referral to see a mental health specialist. However, some Medicare Advantage plans require:

• A referral from your primary care provider

• Prior authorization for certain services like psychological testing or hospital admission

Check your plan’s rules carefully. Denied services due to missing authorization can leave you responsible for the full bill.

Preventive Mental Health Services Are Fully Covered

Medicare covers certain mental health services at no cost to you when used for prevention, including:

• Annual depression screening (once every 12 months)

• Alcohol misuse screening and counseling

• Welcome to Medicare visit (within 12 months of Part B enrollment)

• Annual wellness visit (includes cognitive assessment)

These services must be delivered by a Medicare-assigned provider to be free. If additional counseling or treatment is recommended after screening, standard cost-sharing will apply.

Documentation and Compliance Matter

To ensure Medicare continues to cover your therapy, your provider must document:

• Medical necessity of the treatment

• Your treatment plan and progress

• Your diagnosis and ongoing symptoms

Incomplete documentation could trigger audits or denials. Be sure your provider follows Medicare guidelines for note-taking and billing codes.

You can request a copy of your records to verify proper documentation is being kept.

What Happens if You Switch Providers or Plans?

Changing your therapist or switching from Original Medicare to Medicare Advantage (or vice versa) can complicate your therapy coverage. Here’s how to manage the transition:

• Make sure your new provider accepts Medicare or is in-network for your plan

• Notify Medicare or your Advantage plan of the change to ensure continuity

• Coordinate records transfer and get prior authorization if required

Switching plans can also affect drug coverage. Double-check the formulary for any mental health medications to avoid gaps.

When to Appeal a Denial

If Medicare denies coverage for a therapy session, medication, or hospital stay, you have the right to appeal. Don’t assume the denial is final.

Here’s what to do:

• Review the Explanation of Benefits (EOB) or denial letter

• Contact the provider to clarify billing codes or documentation

• File an appeal within the specified deadline, usually 120 days

If the appeal is denied again, you can escalate through multiple levels, including requesting an Administrative Law Judge (ALJ) hearing.

Key Timelines You Should Track

• Annual Enrollment Period: October 15 to December 7 (to switch plans for 2026)

• Telehealth in-person visit: Must occur at least once every 12 months

• Wellness visit: Annually, tied to your Part B enrollment date

• Depression screening: Every 12 months

Mark these dates to avoid gaps in care or denied claims.

Taking Full Advantage of Your Coverage

With so many moving parts, your Medicare mental health benefits may seem overwhelming. But the system is designed to support your well-being if you meet the requirements and stay organized.

• Verify that your providers are Medicare-approved

• Track your deductibles and coinsurance

• Schedule preventive services annually

• Use your wellness visits to raise mental health concerns

• Communicate any changes in coverage, medication, or providers

By staying proactive, you can ensure uninterrupted access to the care you need.

Don’t Leave Mental Health Care to Chance in 2025

Your Medicare coverage for therapy and mental health care is stronger than ever, but it also comes with rules that you must actively follow. From provider eligibility to required in-person visits, there are several ways coverage can be lost if you’re not careful.

Now is the time to review your current plan, verify your therapists’ Medicare enrollment, and schedule any overdue check-ins or screenings.

If you need help understanding your options or making changes to your coverage, reach out to a licensed agent listed on this website for expert assistance.