This One Medicare Requirement Might Keep You from Getting the Mental Health Help You Need

Key Takeaways

• Medicare offers broad mental health coverage, but specific requirements like provider eligibility and in-person visit rules can delay or block access to services.

• Understanding which professionals are covered and complying with periodic in-person visit mandates is critical for uninterrupted care, especially with telehealth.

Medicare’s Mental Health Promise Comes with Conditions

On the surface, Medicare appears to be one of the most comprehensive programs for mental health care available to older adults. It covers inpatient psychiatric treatment, outpatient therapy, medication management, and even intensive programs like partial hospitalization. However, one key requirement could quietly stand between you and the help you need: the provider must be Medicare-approved and meet certain conditions, including the delivery method of care.

If you’re expecting to call a counselor and schedule a session like you might with physical health providers, you may be surprised to hit a wall. Some mental health professionals don’t accept Medicare. Others may be covered, but only if you comply with in-person visit rules that are reappearing in late 2025.

Knowing where these requirements live—and how to work around them—is essential.

Who You Can See: Medicare-Covered Providers

As of 2025, Medicare Part B covers a broad range of mental health professionals:

• Psychiatrists (MDs or DOs)

• Clinical psychologists (PhDs or PsyDs)

• Clinical social workers (LCSWs)

• Nurse practitioners and physician assistants (when working in mental health)

• Licensed marriage and family therapists (LMFTs)

• Licensed mental health counselors (LMHCs or LPCs)

The final two categories—LMFTs and LMHCs—were only added in 2024. While that change has expanded the provider pool, not all of these professionals are enrolled in Medicare. If a provider isn’t officially participating in Medicare, you’ll either pay full cost or be unable to receive care.

To avoid delays in treatment, always confirm that your therapist, counselor, or psychiatrist is Medicare-assigned or participating. Use Medicare’s online provider lookup or call the office directly.

The In-Person Requirement You Shouldn’t Ignore

Here’s the rule that often catches people off guard: if you’re receiving mental health care through telehealth under Medicare, you must have had an in-person, face-to-face visit with the provider within the last 12 months.

This requirement was waived during the COVID-19 pandemic and its immediate aftermath. However, Medicare reinstates the rule starting October 1, 2025, for most telehealth mental health services.

There are exceptions, such as if you:

• Are diagnosed with certain severe conditions requiring ongoing telehealth services

• Live in a rural or underserved area

• Are receiving care from a mobile or community-based clinic

Still, most beneficiaries will need to comply or risk interruption in virtual care. If you don’t attend an in-person visit once every 12 months, Medicare may stop covering your telehealth therapy sessions or psychiatric appointments.

What Medicare Covers for Mental Health

Despite this requirement, Medicare remains a strong payer for mental health services—if you use it correctly. Here’s a breakdown of what it typically covers:

Inpatient Coverage (Part A)

• Up to 190 days in a lifetime for psychiatric hospitalizations

• General hospital mental health admissions (not counted against the 190-day limit)

• Includes room, meals, nursing, and therapy

• Deductible applies ($1,676 in 2025), plus coinsurance after 60 days

Outpatient Services (Part B)

• Therapy with eligible providers (including LMFTs and LMHCs)

• Psychiatric evaluations and medication management

• Partial hospitalization programs (PHPs)

• Intensive outpatient programs (IOPs)

• Depression screenings and diagnostic assessments

You pay 20% of the Medicare-approved amount after meeting the $257 Part B deductible in 2025.

Prescription Medications (Part D)

• Antidepressants, antipsychotics, anti-anxiety medications, and mood stabilizers

• Subject to plan formularies, deductibles (up to $590 in 2025), and cost-sharing

• Capped annual out-of-pocket cost of $2,000 under the 2025 drug reforms

When Access Gets Denied

The biggest obstacle Medicare enrollees face when trying to get mental health care isn’t coverage—it’s access. The issues usually fall into these categories:

• The provider doesn’t take Medicare. Many counselors, especially those in solo or private practice, choose not to enroll.

• The provider is booked. Even those who do accept Medicare may have limited availability due to high demand.

• You haven’t completed your in-person visit. As of late 2025, if you only use telehealth without seeing your provider face-to-face annually, your coverage may lapse.

• Prior authorization or referrals are missing. Certain settings or services, such as partial hospitalization programs, may require pre-approval.

Understanding these access blockers helps you plan ahead, rather than waiting until your claim is denied.

What You Can Do to Prepare

If you want your Medicare mental health coverage to work smoothly, you need to plan proactively:

• Use Medicare’s official provider search tool to find therapists, psychologists, or psychiatrists who accept your plan.

• Verify provider enrollment before your first appointment. Ask directly if they accept Medicare assignment.

• Schedule your annual in-person visit now if you’re using telehealth. Mark your calendar before October 2025 so you stay compliant.

• Ask your provider about hybrid care models. Some practices offer rotating in-person and virtual sessions to meet the rule.

• Keep documentation of all visits and referrals in case of billing issues or audits.

• Review your Part D plan annually. Check if your mental health prescriptions are covered and whether the drug tier affects your cost.

How Medicare Advantage Plans Compare

Medicare Advantage (Part C) plans must cover at least the same mental health services as Original Medicare, but they may offer additional perks like:

• Lower copays for therapy

• Wellness programs

• Behavioral health hotlines

• Expanded telehealth coverage

However, these plans often come with network restrictions, meaning you’ll have to see providers within their system. Prior authorizations may be stricter as well. Even though premiums may look attractive, out-of-pocket costs can vary, especially if you go out of network.

You should always review your plan’s Summary of Benefits each year, particularly during Medicare Open Enrollment from October 15 to December 7, to confirm your mental health care is still adequately supported.

Telehealth After 2025: What Changes and What Doesn’t

Teletherapy became a lifeline during the pandemic, and Medicare expanded its coverage quickly. The good news is, as of 2025, telehealth remains a permanent part of Medicare mental health coverage. However, changes are coming:

• Video and audio-only visits are still allowed, depending on provider discretion

• In-person visit must occur at least once every 12 months for continued telehealth coverage (starting October 1, 2025)

• Some exceptions apply for hardship, rural access, or clinical necessity

If you rely on telehealth for therapy or psychiatry, this rule will directly affect you. You should prepare for a transition period in late 2025.

Don’t Rely on Medicare Alone to Inform You

Medicare rules are complex and often change annually. It’s not enough to assume you’ll get notified. Instead:

• Track your provider visits and coverage rules on your own calendar

• Speak directly with your provider about Medicare documentation or compliance

• Consult your plan documents each fall when the Annual Notice of Change is released

You can also reach out to a licensed agent listed on this website for one-on-one guidance. They can help you understand:

• Whether you’re compliant with the in-person requirement

• How to switch providers if yours doesn’t accept Medicare

• What your plan’s mental health benefits include

• Which prescriptions are covered under your Part D plan

Getting the Mental Health Care You Deserve

Medicare has made impressive progress in mental health coverage, especially with the inclusion of new licensed counselors and ongoing telehealth flexibility. But these gains come with fine print. The in-person visit rule, the need for Medicare-approved providers, and possible access bottlenecks all require your attention.

With the October 1, 2025 in-person requirement returning, you don’t want to wait until the last minute. Schedule your face-to-face visit now if you’re receiving telehealth care. Keep your records organized, understand your plan’s coverage rules, and ask questions before committing to a provider.

Need help decoding your coverage or switching to a provider who accepts Medicare? Contact a licensed agent listed on this website for personalized support.