At least one in five older Americans has a mental disorder. Among Medicare beneficiaries age 65 and older, the most common mental disorders are depression, anxiety, dementia, and other neurocognitive impairments. By 2030, the number of older people with such disorders is expected to double.
Mental disorders seldom occur in isolation and can often lead to serious physical health issues. For example, depression is associated with increased risk of coronary heart disease and premature death. Depression also often co-occurs with substance abuse disorder and other chronic illnesses such as Alzheimer’s disease, cancer, and arthritis.
However, they are frequently undiagnosed or misdiagnosed in older patients, and older adults are more likely than younger adults to receive inappropriate or inadequate mental health services. One reason is that primary care practitioners—who provide most mental health care under Medicare—have insufficient training in the assessment and treatment of mental disorders associated with aging. Although geriatric mental health assessment tools exist, their use is often not part of routine practice. Perceived social stigma and denial can also impede accurate diagnosis and treatment.
Many older people are reluctant to seek counseling to help them cope with the challenges of later life such as bereavement, disability, loneliness, and isolation, which may explain why older Americans are disproportionately likely to die by suicide.
While Medicare’s coverage of mental health and substance abuse services has improved over the years, restrictions that do not apply to other health services remain, such as a lifetime limit of 190 days for psychiatric care in freestanding psychiatric hospitals. Despite growing evidence supporting the effectiveness of multi-disciplinary, community-based geriatric mental health treatment teams (e.g., physicians, social workers, nurses, psychologists, and pharmacists), Medicare limits access to this type of care.
Medicare covers some mental health-related preventive services with no cost-sharing including annual screenings for depression and alcohol-misuse screening, but coverage for subsequent services can be limited. For those who screen positive for alcohol misuse, Medicare will cover four brief, face-to-face behavioral counseling interventions per year (see also this chapter’s section on Specific Needs and Services—Mental Health for a broader discussion of mental health issues).
Medicare covers outpatient mental health services provided by physicians (especially psychiatrists), clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician assistants. Medicare does not cover treatment by licensed professional counselors. For beneficiaries in rural areas, Medicare will pay only for mental health services delivered via tele-health (video conference) to an approved location by a qualified mental health professional.
The Affordable Care Act (ACA) made some significant improvements to Medicare’s mental health service coverage. For example, Medicare Part D now covers barbiturates and benzodiazepines, which were originally excluded from Part D coverage. The ACA also eliminated cost-sharing for certain Medicare-covered preventive services and authorized CMS to add coverage of additional preventive services through the National Coverage Determination process.
Based on the large and growing number of older adults who misuse substances like alcohol and prescription drugs, demand for mental health and substance abuse services is also expected to grow with the aging of the baby-boom cohort. The anticipated increase in demand for such services may be difficult to meet because older adults already have a tremendous unmet need for them.
MEDICARE MENTAL HEALTH SERVICES: Policy
Access to mental health services
Medicare should provide more adequate reimbursement for mental health and substance abuse services, and should eliminate the 190-day lifetime limit on inpatient psychiatric care in freestanding psychiatric hospitals under Part A.
Medicare should expand the list of mental health professionals who can be reimbursed under Medicare to cover all providers who are fully licensed by their state for independent practice.
Medicare should expand its coverage of outpatient services that have been shown to help individuals with mental illnesses remain in the community.
CMS should ensure Medicare beneficiaries’ access to appropriate, high-quality mental health and substance abuse services, such as outpatient services and partial hospitalization services, as well as ensure access to such preventive services as screening for depression and alcohol misuse.
CMS should ensure that Medicare beneficiaries with mental health or substance abuse problems, particularly those residing in nursing homes or enrolled in managed care plans, have access to appropriate services. Data collection and other oversight activities must preserve beneficiary privacy and confidentiality.