Published by: Medicare.gov

People with Medicare Part D (drug coverage) can get even more covered vaccines, including RSV, shingles, whooping cough, and more to help keep them healthy in the new year.

Medicare also covers many preventive and screening services. These services can help keep you from getting sick and can help find health problems early when treatment is most likely to work best. Talk to your doctor about which ones might be right for you.

If you have Original Medicare (Part A and Part B), log into your secure Medicare account to see a personalized list of current and upcoming preventive services. If you don’t already have an account, signing up is free and easy.

If you’re in a Medicare Advantage Plan, contact your plan for a list of covered preventive services. MA Plans must cover all the same preventive services as Original Medicare, and some may offer additional services.

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If you have Original Medicare, your Part B costs once you have met your deductible can vary depending on the type of provider you see. There are three types of providers for cost purposes, meaning three different relationships a provider can have with Medicare. A provider’s type determines how much you will pay for Part B-covered services.

Participating providers accept Medicare and always take assignments. Taking an assignment means the provider accepts Medicare’s approved amount for health care services as full payment. These providers must submit a bill (also called filing a claim) to Medicare for the care they receive. Medicare will process the bill and pay your provider directly for your care. If your provider does not file a claim for your care, there are troubleshooting steps to help resolve the problem. If you see a participating provider, you are responsible for paying a 20% coinsurance for Medicare-covered services. Certain providers, such as clinical social workers and physician assistants, must always take assignments if they accept Medicare.

 Non-participating providers accept Medicare but do not agree to take assignments in all cases (they may on a case-by-case basis). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicare’s approved amount for health care services as full payment. Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services they receive (known as the limiting charge). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services. Some states may restrict the limiting charge when you see non-participating providers. For example, New York State’s limiting charge is set at 5%, instead of 15%, for most services. For more information, contact your State Health Insurance Assistance Program (SHIP).

Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services but must follow certain rules to do so. Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You are responsible for the entire cost of your care. The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you. Opt-out providers do not bill Medicare for services you receive. Many psychiatrists opt out of Medicare.

Be sure to ask your provider if they are participating, non-participating, or opt-out. You can also check by using Medicare’s Physician Compare tool.

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Social Security beneficiaries will soon get notices showing exactly how much money to expect in their monthly checks for 2024.

Those recipients are slated to get a 3.2% boost to their benefits starting in January with the 2024 annual cost-of-living adjustment. Retirement benefits are expected to go up by more than $50 per month, on average.

One factor that will affect exactly how much beneficiaries receive is their Medicare Part B premium, which is typically deducted directly from Social Security checks.

Medicare Part B serves as medical insurance and covers doctor and other provider services, outpatient care, home health care, durable medical equipment and some preventive services.

Standard monthly premiums are slated to rise by $9.80 per month to $174.70 in 2024, from $164.90 per month this year.

However, people with higher incomes will pay more as a result of what is called income-related monthly adjustment amounts, or IRMAA.

When to appeal your Medicare Part B premium

You generally can’t have your Medicare Part B premiums adjusted — with one exception, according to Tim Steffen, director of advanced planning at financial services company Baird.

“If something has materially changed in your situation, you can appeal your Medicare premium,” Steffen said.

That applies to events that have caused your income to go down since 2022, such as a divorce, the death of a spouse, the loss of a pension or starting retirement.

You may file an appeal once you receive your benefit notice for 2024.

Medicare Part B premiums are based on beneficiaries’ modified adjusted gross income from two years prior. Therefore, 2024 Part B premiums are based on your 2022 federal tax returns.

That includes adjusted gross income — wages, retirement distributions, investment income, capital gains, rental income and Social Security benefits — as well as tax-exempt interest.

If you have municipal bond interest that you don’t pay federal taxes on because it is exempt, that can still prompt higher Medicare Part B premiums, Steffen said.

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Medicare should cover alcoholism and substance use disorder treatment for a parent if:

• Their provider states that their services are medically necessary
• They receive services from a Medicare-approved provider or facility
• And, their provider sets up their plan of care

Medicare covers treatment in both inpatient and outpatient settings. Here are just a few examples of the services that Medicare covers:

• Psychotherapy
• Opioid treatment program (OTP) services
• Patient education regarding diagnosis and treatment
• Post-hospitalization follow-up

Part A should cover their care if they are hospitalized and needs substance use disorder treatment. If they are in an inpatient psychiatric hospital, keep in mind that Medicare only covers a total of 190 lifetime days. Once their limit has been reached, though, Medicare may cover care at a general hospital. A plan’s cost-sharing rules for an inpatient hospital stay should apply.

Part B should cover outpatient substance use disorder care they receive from a clinic, hospital outpatient department, or opioid treatment program. Original Medicare covers these services at 80% of the Medicare-approved amount. As long as they receive the service from a participating provider, they will pay a 20% coinsurance after meeting their Part B deductible. Visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to find participating providers. If they are enrolled in a Medicare Advantage Plan, contact their plan for information about costs, coverage, and in-network providers for substance use disorder treatment.

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Medicare covers both inpatient and outpatient mental health care. And Medicare prescription drug plans cover medications used to treat mental health conditions, but be sure to check the formulary to ensure the brands and dosages you take are included.

 Medicare Part B covers outpatient mental health care, including the following services:

• Individual and group therapy
• Substance use disorder treatment
• Tests to make sure you are getting the right care
• Occupational therapy
• Activity therapies, such as art, dance, or music therapy
• Training and education (such as training on how to inject a needed medication or education about your condition)
• Family counseling to help with your treatment
• Laboratory tests
• Prescription drugs that you cannot administer yourself, such as injections that a doctor must give you
• An annual depression screening

 Be sure to ask any provider you see if they take your Medicare insurance before you begin receiving services. If they don’t, you will likely be responsible for the full cost of the care. Psychiatrists are more likely than any other type of physician to opt out of Medicare, meaning Medicare will not cover any of the cost of the care from those doctors. Additionally, not all non-medical providers (like psychologists or clinical social workers) are Medicare-certified. If you need a list of providers near you who accept Medicare, you can go to www.medicare.gov/care-compare. 

 Medicare Part A covers inpatient mental health care that you receive in either a psychiatric hospital (a hospital that only treats mental health patients) or a general hospital. Your provider should determine which hospital setting you need.

If you receive care in a psychiatric hospital, Medicare covers up to 190 days of inpatient care in your lifetime. If you have used your lifetime days but need additional mental health care, Medicare may cover your care at a general hospital.

 Medicare Part D covers most prescription drugs used to treat mental health conditions. You may have Part D coverage through a Medicare Advantage Plan or through a stand-alone Part D plan. All Part D plans must cover at least two drugs from most drug categories and must cover all drugs available in certain categories, including antidepressants and antipsychotic medications.

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Medicare Part B covers certain doctor’s services, outpatient care, medical supplies, and preventive services.

• One depression screening per year. The screening must be done in a primary care doctor’s office or primary care clinic that can provide follow-up treatment and referrals.
• Individual and group psychotherapy with doctors (or with certain other licensed professionals, as the state where you get the services allows).
• Family counseling, if the main purpose is to help with your treatment.
• Testing to find out if you’re getting the services you need and if your current treatment is helping you.
• Psychiatric evaluation.
• Medication management.
• Certain prescription drugs aren’t usually “self-administered” (drugs you would normally take on your own), like some injections.
• Diagnostic tests.
• Partial hospitalization.
• A one-time “Welcome to Medicare” preventive visit. This visit includes a review of your possible risk factors for depression.
• A yearly “Wellness” visit. Talk to your doctor or other healthcare provider about changes in your mental health since your last visit.

Part B also covers outpatient mental health services for the treatment of substance abuse.

Your costs in Original Medicare

You pay nothing for your yearly depression screening if your doctor or healthcare provider accepts the assignment.

After you meet the Part B deductible, you pay 20% of the Medicare-Approved Amount for visits to your doctor or other healthcare provider to diagnose or treat your condition.

If you get your services in a hospital outpatient clinic or hospital outpatient department, you may have to pay an additional copayment or coinsurance amount to the hospital.

What it is

Mental health services help diagnose and treat people with mental health disorders, like depression and anxiety. These visits are often called counseling or psychotherapy.

Things to know

Part B covers mental health services and visits with these types of health professionals:

• Psychiatrists or other doctors
• Clinical psychologists
• Clinical social workers
• Clinical nurse specialists
• Nurse practitioners
• Physician assistants

Medicare only covers the visits if you get them from a healthcare provider who accepts assignments.

Part B covers outpatient mental health services, including services that are usually provided outside a hospital, in these types of settings:

• A doctor’s or other health care provider’s office
• A hospital outpatient department
• A community mental health center

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All Medicare Advantage Plans must set an annual limit on your out-of-pocket costs, known as the maximum out-of-pocket (MOOP). This limit is high but it may protect you from excessive costs if you need a lot of care or expensive treatments. After reaching your MOOP, you will not owe cost-sharing for Part A or Part B covered services for the remainder of the year. Some plans may also apply the MOOP to supplemental benefits, such as vision, hearing, or dental.

The out-of-pocket costs that help you reach your MOOP include all cost-sharing (deductibles, coinsurance, and copayments) for Part A and Part B covered services that you receive from in-network providers. Part D cost-sharing does not count toward your plan’s MOOP.

In 2023, the MOOP for Medicare Advantage Plans is $8,300, but plans may set lower limits. If you are in a plan that covers services you receive from out-of-network providers, such as a PPO, your plan will set two annual limits on your out-of-pocket costs. One limit is for in-network costs and the other is for combined in-network and out-of-network costs.

Call your plan directly if you have questions about your annual out-of-pocket limit.

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It is usually best if someone enrolls in Medicare when they are first eligible. As you mentioned, many people who delay enrolling in Medicare must wait for the General Enrollment Period and then may owe a late enrollment penalty for life.

Beginning this year, though, if someone misses a first-time enrollment period, there are certain situations when they might qualify for exceptional circumstances Special Enrollment Period (SEP).  One of these new SEPs is for people who were released from the custody of a penal authority, including a prison, after January 1, 2023.

To be eligible for this SEP, he would have to:

• Be eligible for Medicare
• Have failed to enroll in Medicare while he was incarcerated
• Be released on or after January 1, 2023

Note that Medicare defines “incarcerated” as individuals who are in the custody of certain authorities, including people under arrest, imprisoned, residing in halfway houses, living under home detention, or confined completely or partially in any way under a penal statute or rule.

• If he is eligible, the SEP lasts for twelve months.
• The SEP starts the day he was released.
• The SEP ends the last day of the twelfth month after his release.

He can choose to have his coverage begin on the first of the month after he signs up, or to have it begin up to six months retroactively (but not before January 1, 2023, or before his release ). If he uses this SEP to enroll in Medicare, he will not owe a late enrollment penalty. To use this SEP, he should contact SSA.

If he then wants to enroll in a Medicare Advantage Plan or stand-alone Part D prescription drug plan, he should contact 1-800-MEDICARE (1-800-633-4227) to learn more about his enrollment period options. He may qualify for a Medicare Advantage or Part D SEP or have other enrollment periods available, depending on when he enrolls in Part B.

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