GAO: A look at cost-sharing for behavioral health in traditional Medicare, MA

Enrollees in both traditional Medicare and Medicare Advantage (MA) have cost-sharing obligations for behavioral health services, according to a new report from the Government Accountability Office (GAO).

GAO researchers analyzed data and manuals from the Centers for Medicare & Medicaid Services (CMS), covering both Medicare and MA coverage offered in 2024, along with guidance and other regulations. They found that beneficiaries enrolled in traditional Medicare typically had deductibles and coinsurance on inpatient services as well as coinsurance for many outpatient offerings.

For 2024, for example, enrollees must pay a $1,632 deductible for any psychiatric hospital stay of up to 60 days, with coinsurance payments due for additional stay days.

The report said that a quarter of the 66.7 million people enrolled in Medicare are effected by mental health conditions.

"When these disorders go untreated, individuals may suffer potential consequences, such as worsening health, frequent emergency department visits, hospitalizations, or premature death," the researchers wrote. "For these reasons, access to services is important for Medicare beneficiaries to manage their behavioral health conditions."

In MA, meanwhile, enrollees had copayments on inpatient and outpatient behavioral health services, though the specific costs varied between plans. The study found that at least 70% of the plans analyzed required a copay for a visit with a behavioral health provider, with the median copay coming in at $30.

MA plans also have the ability to offer supplemental coverage options that traditional Medicare does not. The study noted that nearly 30% of plans offered coverage for tobacco and smoking cessation visits as an outpatient service.

In addition, 8% covered more days of inpatient psychiatric care, according to the report.

Outpatient services covered by Medicare include psychotherapy, physician visits, opioid use disorder treatment, partial hospitalization programs and screenings for behavioral health conditions.

CMS also sets cost-sharing limits in MA that impact what enrollees are paying for these services, according to the report.