Georgia Medicare Outpatient Mental Health Benefit

Georgia Medicare outpatient mental health coverage has just been through the most consequential expansion in two decades, and most families have not heard about it. Until January 1, 2024, the set of providers authorized to bill Medicare directly for outpatient mental health services was tightly bounded: psychiatrists, clinical psychologists (qualified psychologist services, Section 1861(s)(2)(M) of the Social Security Act, defined at Section 1861(ii)), clinical social workers (Section 1861(s)(2)(N), defined at Section 1861(hh)(2)), and nurse practitioners and physician assistants providing services within their scope. Marriage and family therapists, licensed professional counselors, and mental health counselors, who together represent the bulk of the outpatient behavioral health workforce in the United States, could not bill Medicare directly. For Georgia, where licensed professional counselors and marriage and family therapists form the backbone of the outpatient behavioral health workforce, this gap forced thousands of Medicare beneficiaries to either pay out of pocket or hunt for the limited supply of LCSWs and psychologists accepting new Medicare patients.

The Consolidated Appropriations Act 2023 (Public Law 117-328) changed this landscape on January 1, 2024. Section 4121 of CAA 2023 added Section 1861(lll) to the Social Security Act (with the matching coverage authority at Section 1861(s)(2)(II)), authorizing marriage and family therapists (MFTs) and mental health counselors (MHCs, including licensed professional counselors) as Medicare providers. Section 4124 of CAA 2023 added Section 1861(ff)(4), defining intensive outpatient services (IOP) as a new Medicare benefit, closing the gap between standard outpatient therapy and partial hospitalization. For Georgia beneficiaries, these two expansions together nearly doubled the practical access points for outpatient mental health care.

This guide covers Georgia Medicare outpatient mental health end to end: who can bill, what is covered, what it costs in 2026, the 190-day lifetime cap on freestanding psychiatric hospital admissions, and where in Georgia to actually get care, from DBHDD and the Community Service Boards to private practices, FQHCs, and telehealth. Four worked examples show how the money lands, and a list of common mistakes shows what costs Georgia families access every year.

Federal Statutory and Regulatory Framework

A small set of Social Security Act provisions define coverage, provider authority, payment, and beneficiary cost-sharing. Reading them in sequence is what explains how a 78-year-old Georgia beneficiary can see a licensed marriage and family therapist for couples therapy in 2026 when she could not have in 2023.

Where the Outpatient Mental Health Benefit Actually Lives in the Statute

There is no single "outpatient mental health" subparagraph in the Social Security Act. Section 1861(s)(2) lists the "medical and other health services" Part B covers, and the mental health benefit is assembled from several of its entries plus the definitions they point to:

• Qualified psychologist services: Section 1861(s)(2)(M), defined at Section 1861(ii)
• Clinical social worker services: Section 1861(s)(2)(N), defined at Section 1861(hh)(2)
• Marriage and family therapist and mental health counselor services: Section 1861(s)(2)(II), defined at Section 1861(lll)(1) and (lll)(3)
• Partial hospitalization and intensive outpatient services: Section 1861(s)(2)(B), which covers hospital services incident to physicians' services rendered to outpatients "and partial hospitalization services or intensive outpatient services incident to such services," defined at Section 1861(ff)
• Opioid treatment program services: Section 1861(s)(2)(HH), defined at Section 1861(jjj)

Psychotherapy and medication management furnished by a psychiatrist are covered as physicians' services. The sections below walk each authority in turn.

Section 1861(ii): Qualified Psychologist Services

Clinical psychologists became authorized independent Medicare providers under the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239). Section 1861(ii) of the Social Security Act and the implementing regulation at 42 CFR 410.71 require: a doctoral degree in psychology from an accredited educational institution, two years of supervised clinical experience (one of which must be post-doctoral), licensure or certification as a psychologist by the state in which the services are furnished, and practice within the scope of state law. Clinical psychologists bill Medicare independently under their own National Provider Identifier (NPI). They are paid at 100 percent of the Medicare Physician Fee Schedule (MPFS) rate for mental health services.

Section 1861(hh): Clinical Social Worker Services

Clinical social workers became authorized independent Medicare providers under OBRA 1989 alongside clinical psychologists; their services are covered at Section 1861(s)(2)(N). Section 1861(hh) and 42 CFR 410.73 require: a master's degree or doctorate from an accredited school of social work, two years of supervised clinical experience after the master's degree, state licensure (in Georgia, the Licensed Clinical Social Worker or LCSW license issued by the Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists), and practice within state scope. LCSWs bill Medicare under their own NPI. Critically, LCSWs are paid at 75 percent of the rate a clinical psychologist would be paid (not 100 percent). This 25 percent payment differential has been the subject of repeated advocacy efforts by social work organizations seeking parity with psychologists, but as of 2026 the differential remains in place.

Section 1861(lll): Marriage and Family Therapist and Mental Health Counselor Services

Section 1861(lll) was added to the Social Security Act by Section 4121 of the Consolidated Appropriations Act 2023 (Public Law 117-328), effective January 1, 2024, with the matching coverage authority added at Section 1861(s)(2)(II). The provision authorizes two new categories of Medicare mental health providers:

1. Marriage and Family Therapist (MFT): a person who holds a master's or doctoral degree in marriage and family therapy (or a related discipline) from an accredited educational program, has performed at least two years of clinical supervised experience in marriage and family therapy after the qualifying degree, is licensed or certified as a marriage and family therapist by the state in which the services are furnished, and meets other criteria specified by the Secretary.

2. Mental Health Counselor (MHC): a person who holds a master's or doctoral degree in counseling, mental health counseling, or a related field from an accredited educational program, has performed at least two years of clinical supervised experience in mental health counseling after the qualifying degree, is licensed or certified as a mental health counselor or professional counselor by the state in which the services are furnished, and meets other criteria specified by the Secretary. In Georgia, the relevant license is the Licensed Professional Counselor (LPC).

Medicare Part B pays MFTs and MHCs 75 percent of what a clinical psychologist is paid under the Medicare Physician Fee Schedule, the same treatment LCSWs get, and the beneficiary pays the standard Part B cost-sharing: 20 percent of the Medicare-approved amount after the annual deductible. The expansion was implemented through CMS rulemaking in the 2024 Medicare Physician Fee Schedule Final Rule, which set enrollment procedures, billing requirements, and supervision standards.2

The practical effect of Section 1861(lll) is enormous. In Georgia alone, the addition of LPCs and LMFTs to the Medicare-billing provider pool roughly doubled the licensed behavioral health workforce that could see Medicare patients. For specialized services such as couples and family therapy that are traditionally the domain of MFTs, the expansion was particularly significant, because LCSWs and psychologists historically did less couples and family work.

Section 1861(ff)(1): Partial Hospitalization Services

Section 1861(ff)(1) of the Social Security Act defines partial hospitalization services, and Section 1861(ff)(3) defines the program that furnishes them. A partial hospitalization program (PHP) is a structured program of outpatient psychiatric services offered as an alternative to inpatient psychiatric care, usually four to eight hours of care a day, for patients who do not require 24-hour care. The statute and implementing regulation at 42 CFR 410.43 require:

1. The services must be furnished under an individualized, written plan of treatment established and periodically reviewed by a physician.
2. The patient must be under the active care of a physician, who must certify that the patient would otherwise need inpatient psychiatric treatment.
3. A physician must determine, not less frequently than monthly, that the patient needs these services for a minimum of 20 hours per week. This is a finding about the patient's need, not a promise about how many hours the program keeps its doors open.
4. Services must be furnished by a hospital outpatient department or a Community Mental Health Center (CMHC).

PHP is paid under OPPS as a per-day rate.6

Section 1861(ff)(4): Intensive Outpatient Services

Section 1861(ff)(4) was added by Section 4124 of CAA 2023, effective January 1, 2024. It defines intensive outpatient services (IOP) by pointing back to the partial hospitalization definition with three changes, which is what makes IOP the lighter-touch benefit:

1. The physician determination drops from a minimum of 20 hours per week to a minimum of 9 hours per week, and is made not less frequently than once every other month rather than monthly (typically three days a week, three hours a day).
2. The setting list widens: alongside a hospital outpatient department and a CMHC, IOP may be furnished by a Federally Qualified Health Center or a Rural Health Clinic. That matters in rural Georgia, where an FQHC or RHC is often the only behavioral health provider within an hour's drive.2
3. The requirement that the patient would otherwise need inpatient care does not apply.

Opioid treatment programs may also furnish intensive outpatient services, but only as part of the OTP benefit for opioid use disorder, which is a separate authority described below.7

IOP is paid under OPPS at a per-day rate established by CMS in the 2024 OPPS Final Rule and updated annually.8

Section 1812(b)(3): 190-Day Lifetime Inpatient Psychiatric Limit

Section 1812(b)(3) of the Social Security Act caps Medicare coverage of inpatient psychiatric services in freestanding psychiatric hospitals at 190 days over the beneficiary's lifetime. This is fundamentally different from the structure of general hospital coverage under Section 1812(a)(1), which uses a renewable benefit period: up to 90 covered days per benefit period, and the benefit period itself starts fresh once the beneficiary has gone 60 consecutive days without inpatient hospital care or skilled care in a SNF. The 60 lifetime reserve days are the one piece that never renews. They are a single 60-day reserve for the whole of a beneficiary's life, not 60 more days per benefit period, and once they are spent they are gone.9

The cap applies only to freestanding psychiatric hospitals classified as Institutions for Mental Diseases. Inpatient psychiatric care furnished in a general hospital is not counted against it and is not subject to it.3 It is non-renewable: once exhausted, no further Medicare coverage in freestanding psychiatric hospitals is available. It was enacted with the Medicare program in 1965 and has never been amended despite repeated reform proposals. The section below lists which Georgia facilities fall on which side of that line, and it is the single most consequential piece of planning for a family facing recurrent psychiatric admissions.

Section 1833(c) and the MIPPA 2008 Mental Health Treatment Limitation Phase-Out

From 1965 through 2013, Medicare imposed a 50 percent coinsurance on outpatient mental health services rather than the standard 20 percent for other Part B services. The mechanism was a limitation on the amount of charges that could count toward the "Medicare-approved" amount for mental health services. The practical effect: a Georgia beneficiary owed 50 percent of an outpatient psychotherapy bill, compared to 20 percent for a same-cost physical therapy session. This produced major access barriers and discouraged beneficiaries from seeking care.

Section 102 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA 2008, Public Law 110-275) phased out the mental health treatment limitation over four years (2010–2013), with the standard Part B 20 percent coinsurance taking effect on January 1, 2014.

Effective January 1, 2014, outpatient mental health is at parity with other Part B services. The 50 percent coinsurance is gone, but the legacy effect persists: many older beneficiaries still believe Medicare imposes higher mental health cost-sharing, and many providers report patients delaying care based on outdated assumptions.1

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)

The MHPAEA (Public Law 110-343) generally requires group health plans and health insurance issuers in the private market to provide mental health and substance use disorder benefits on parity with medical/surgical benefits. The Act covers financial requirements (deductibles, copays, coinsurance, out-of-pocket maximums) and non-quantitative treatment limitations (prior authorization, step therapy, network access standards). It is a private-insurance statute, so it is not the instrument that delivers parity inside Medicare. For traditional Medicare, parity is achieved structurally instead, through the MIPPA 2008 elimination of the 50 percent coinsurance and the equal application of Part B rules to mental health and physical health.

For Medicare Advantage beneficiaries in Georgia, the operative rules are Medicare's own: an MA plan must cover everything Original Medicare covers, including every outpatient mental health benefit in this guide, and it must comply with mental health parity requirements. What an MA plan may vary is the cost-sharing form, usually a flat copay per visit instead of 20 percent coinsurance.1

Telehealth for Behavioral Health

The Consolidated Appropriations Act, 2021 made behavioral health telehealth permanent, and later appropriations acts have extended the surrounding flexibilities. Effective beyond the COVID public health emergency:

1. Medicare beneficiaries can receive mental health services via telehealth from any geographic location including the beneficiary's home.
2. Audio-only (telephone) telehealth is permitted for behavioral health under specified conditions.
3. Originating site restrictions and the requirement for the patient to travel to a clinical facility were eliminated for behavioral health.
4. The in-person visit requirement that normally attaches to at-home behavioral health telehealth (an in-person service within six months before the first telehealth visit and at least once every 12 months thereafter) has been waived by Congress through December 31, 2027. Unless it is extended again, that requirement is scheduled to take effect only for services furnished on or after January 1, 2028.

For Georgia, telehealth has been transformative for rural areas where in-person mental health providers are scarce. A Medicare beneficiary in rural Georgia can now receive weekly psychotherapy via telehealth from a clinician in Atlanta or any other location, paid under standard Part B with 20 percent coinsurance.5

Section 1861(s)(2)(HH) and SUPPORT Act Opioid Treatment Programs

Section 2005 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act of 2018 (Public Law 115-271, the SUPPORT Act) added Section 1861(s)(2)(HH) to the Social Security Act, creating a Part B benefit category for opioid use disorder treatment services furnished by an OTP on or after January 1, 2020. The companion provision Section 1861(jjj), implemented at 42 CFR 410.67, defines OTP services to include FDA-approved treatment medications (methadone, buprenorphine, naltrexone) and their dispensing, substance use counseling, individual and group therapy, toxicology testing, intake and periodic assessment, and, since January 1, 2024, OTP intensive outpatient services. OTP services are paid as a bundled payment per one-week episode of care.

Cost is the part most families get wrong: the beneficiary's coinsurance or copayment for OTP services is zero, but the annual Part B deductible ($283 in 2026) still applies first. For Georgia, OTPs operate in metro Atlanta, Augusta, Savannah, Columbus, Macon, Albany, and select rural areas.7

What Georgia Medicare Outpatient Mental Health Covers Under Part B

Psychotherapy

Medicare covers individual, group, and family psychotherapy when delivered by an authorized provider. Common CPT codes:

• 90832: Individual psychotherapy, 30 minutes
• 90834: Individual psychotherapy, 45 minutes
• 90837: Individual psychotherapy, 60 minutes
• 90839: Crisis psychotherapy, first 60 minutes
• 90840: Crisis psychotherapy, each additional 30 minutes
• 90846: Family psychotherapy without patient present
• 90847: Family psychotherapy with patient present (couples therapy)
• 90853: Group psychotherapy

Psychiatric Diagnostic Evaluation

• 90791: Psychiatric diagnostic evaluation (by any authorized provider)
• 90792: Psychiatric diagnostic evaluation with medical services (physicians, NPs, PAs only)

Medication Management

Psychiatric medication management is billed by physicians, nurse practitioners, physician assistants, and clinical nurse specialists as E/M codes (99202-99215 for new and established office visits), often with psychotherapy add-on codes (90833 for 16-30 minutes of psychotherapy, 90836 for 38-52 minutes, 90838 for 53+ minutes added to the E/M).

Screening and Prevention Services

Each of these costs the beneficiary nothing when the provider accepts assignment, and each carries its own limit. If a provider does not accept assignment, that protection does not hold.10

• G0444: Depression screening, once every 12 months. Deductible and coinsurance are waived, but the screening must be furnished in a primary care setting that has staff-assisted supports in place for diagnosis, treatment, and follow-up or referral. A second screening inside the same 12 months is not covered.4
• G0442: Annual alcohol misuse screening, for adults who use alcohol but do not meet the medical criteria for alcohol dependency11
• G0443: For those who screen positive, up to 4 brief face-to-face counseling sessions a year, furnished by a primary care practitioner in a primary care setting
• G0396, G0397: SBIRT screening, brief intervention, and referral to treatment
• 99406: Tobacco cessation counseling, 3-10 minutes
• 99407: Tobacco cessation counseling, more than 10 minutes. Medicare covers tobacco cessation counseling for every beneficiary who uses tobacco, whether or not they have a tobacco-related illness, up to 8 sessions in a 12-month period (2 attempts of up to 4 sessions each).12

Health Behavior Assessment and Behavioral Health Integration

Two further families of codes matter mostly because they let a primary care office deliver mental health care without a separate referral. Health behavior assessment and intervention (96156, 96158, 96159, and the group and family variants 96164 to 96171) covers behavioral work aimed at a medical condition. Behavioral health integration and the psychiatric Collaborative Care Model (99484, 99492 to 99494, and G0511, G0512, and G2214 at an FQHC or rural health clinic) pay a primary care practice to manage depression or anxiety with a behavioral care manager and a consulting psychiatrist. If your parent will not see a therapist but will see their doctor, this is the route that works.

Partial Hospitalization and Intensive Outpatient

Both PHP and IOP are paid under OPPS as a per-day rate rather than per service. CMS groups covered outpatient services into Ambulatory Payment Classifications (APCs) and sets a payment rate for each; the PHP and IOP rates are reset in the annual OPPS final rule, most recently the CY2026 OPPS/ASC Final Rule issued November 21, 2025.8

Provider Payment Rates

Medicare pays outpatient mental health providers under the Medicare Physician Fee Schedule (MPFS). The rate depends on the provider's discipline:

The 75 percent figure is set by statute, and it is a percentage of what a clinical psychologist is paid rather than a percentage of some separate schedule. Because psychologists are paid the full fee-schedule amount, the two framings land in the same place. This differential does not change what you owe: the beneficiary pays 20 percent of the Medicare-approved amount after the deductible whichever discipline delivers the therapy. Mental health advocacy organizations have repeatedly sought legislation to raise these rates to parity with psychologists; the Consolidated Appropriations Act, 2023 added the new provider categories but did not change the payment differential.2

What Georgia Medicare Outpatient Mental Health Costs in 2026

• Part B deductible: $283 per year in 2026 (applies to mental health services and all other Part B services collectively)9
• Coinsurance for psychotherapy, medication management, diagnostic evaluation: 20 percent of the Medicare-approved amount after deductible
• Depression screening (G0444), alcohol screening and counseling (G0442, G0443), tobacco cessation counseling (99406, 99407): nothing, when the provider accepts assignment
• PHP and IOP, in a hospital outpatient department: 20 percent of the Medicare-approved amount for the practitioner's services, plus a separate copayment to the hospital for each service

Two bounds on that last line are worth knowing before a bill arrives. First, 20 percent is the statutory baseline for hospital outpatient cost-sharing, not a ceiling that holds on every service: the national unadjusted coinsurance rate for an individual APC is capped at 40 percent, so a particular service can carry an effective rate above 20 percent. Second, the copayment for any one service is capped at the Part A inpatient hospital deductible, $1,736 in 2026, but that cap is per service, so a beneficiary who receives several outpatient services in a stretch of PHP can owe more than $1,736 in total. The cap also does not hold at a critical access hospital, where Medicare says your copayment may be higher and may exceed the Part A deductible. Several of Georgia's rural hospitals are critical access hospitals, so this is not a hypothetical here.8

Supplemental coverage is what flattens all of this. Mental health is not carved out of Medigap: a Medigap policy handles the Part B coinsurance on a therapy visit exactly as it handles the coinsurance on any other Part B service. How much it handles depends on the letter. Plan G and grandfathered Plan F cover the full Part B coinsurance with no copay. Plan N pays 100 percent of the Part B coinsurance except for a copayment of up to $20 for some office visits and up to $50 for an emergency-room visit that does not lead to inpatient admission. High-deductible Plan G (and high-deductible Plan F, for those still eligible for F) is the exception that surprises people: it pays nothing until you have paid $2,950 of Medicare-covered costs yourself in 2026, so early-year therapy sessions come out of pocket.13

Inpatient Psychiatric Coverage and the 190-Day Lifetime Cap

While this guide focuses on outpatient mental health, the inpatient psychiatric framework is closely intertwined and deserves a clear explanation.

Freestanding Psychiatric Hospitals (IMDs)

A freestanding psychiatric hospital is a hospital primarily engaged in providing inpatient psychiatric services, classified as an Institution for Mental Diseases (IMD). Part A will pay for a total of only 190 days of inpatient care in such a hospital over a beneficiary's lifetime, after which no further benefits of that type are available.3

Major Georgia freestanding psychiatric hospitals (IMDs):

• Anchor Hospital (Atlanta, Acadia Healthcare)
• Peachford Hospital (Atlanta, Universal Health Services)
• Ridgeview Institute (Smyrna)
• Riverwoods Behavioral Health (Riverdale, Acadia)
• Lakeview Behavioral Health (Norcross, Acadia)
• Coastal Harbor Health System (Savannah)
• HCA Floyd Behavioral Health (Rome)
• Turning Point Hospital (Moultrie)

Psychiatric Units in General Hospitals

Psychiatric care delivered in a designated psychiatric unit of a general acute care hospital is NOT subject to the 190-day lifetime cap. The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) under 42 CFR Part 412 Subpart N governs payment to both freestanding psychiatric hospitals and to psychiatric units in general hospitals, but the 190-day cap is statutorily limited to freestanding facilities.

Major Georgia psychiatric units in general hospitals:

• Emory Wesley Woods Center (geriatric psychiatry)
• Emory Saint Joseph's Hospital
• Emory Decatur Hospital
• Wellstar Cobb Hospital
• Wellstar Spalding Regional
• Piedmont Athens Regional
• Piedmont Newnan Hospital
• Memorial Health University Medical Center (Savannah)
• Northeast Georgia Medical Center (Gainesville)
• AU Medical Center (Augusta)
• Phoebe Putney Memorial Hospital (Albany)
• Tanner Medical Center (Carrollton)
• Grady Memorial Hospital (Atlanta)

Cost-Sharing for Inpatient Psychiatric

Inpatient psychiatric coverage uses the standard Part A structure:

• Part A inpatient deductible: $1,736 per benefit period (2026)
• No coinsurance for days 1 through 60 of the benefit period
• Coinsurance day 61 through 90: $434 per day (2026)
• Days 91 through 150, drawing on the one-time 60-day lifetime reserve: $868 per day (2026)
• After the lifetime reserve days are exhausted, the beneficiary pays all costs (general hospital limit, separate from the 190-day psych limit)
• Separately, the patient pays 20 percent of the Medicare-approved amount for physician mental health services received while a hospital inpatient3

For freestanding psychiatric hospital admissions, days drawn down also count against the 190-day lifetime cap. For psychiatric unit admissions in general hospitals, no 190-day cap applies, but the standard benefit period structure governs (renewable once the beneficiary has gone 60 consecutive days without inpatient hospital care or skilled care in a SNF).

Georgia Behavioral Health System

Department of Behavioral Health and Developmental Disabilities (DBHDD)

DBHDD is the Georgia state agency overseeing public mental health, substance use, and developmental disabilities services. DBHDD operates a statewide network of 25 Community Service Boards (CSBs), each serving a designated catchment area with outpatient mental health, addiction treatment, and developmental disability services. DBHDD directs residents to the Georgia Crisis and Access Line (GCAL) at 1-800-715-4225 for access to the state's behavioral health crisis system. GCAL takes calls, text, and chat 24 hours a day, 365 days a year, is the home of the 988 Suicide and Crisis Lifeline in Georgia, and can dispatch mobile crisis teams. You can also call or text 988.14

Community Service Boards

Georgia has roughly 25 CSBs covering every county in the state. CSBs are non-profit entities created under Georgia law to provide community-based behavioral health and developmental disability services. CSBs serve as safety-net providers for low-income and Medicaid populations and also serve Medicare beneficiaries, billing Medicare Part B for outpatient mental health services.

Major Georgia CSBs:

• View Point Health (Gwinnett, Newton, Rockdale)
• DeKalb Community Service Board
• Fulton County Behavioral Health Division
• Cobb-Douglas Community Services Board
• Aspire Behavioral Health (Houston, Macon-Bibb, Crawford)
• River Edge Behavioral Health (central Georgia)
• Pathways Center for Behavioral Health (Carroll, Heard, Coweta)
• Highland Rivers Behavioral Health (Northwest Georgia)
• Lookout Mountain Community Services
• Avita Community Partners (Northeast Georgia)
• McIntosh Trail Community Service Board
• Phoenix Center Behavioral Health (Lowndes area)
• Behavioral Health Services of South Georgia
• Unison Behavioral Health (Southeast Georgia)
• Gateway Behavioral Health Services (Coastal Georgia)

Private Practice, Health Centers, and Telehealth

The CAA 2023 expansion grew Georgia's Medicare-billing private practice landscape considerably, as LPCs and LMFTs enrolled from January 1, 2024 onward: solo practices, group practices, behavioral health arms of multispecialty groups, and academic clinics (Emory, AU MCG, Mercer, Morehouse). Federally Qualified Health Centers and rural health clinics commonly fold behavioral health into primary care, using the integration codes above, and they are also an approved setting for IOP. National telehealth platforms now have Medicare-enrolled clinicians serving Georgia, which is often the shortest path to a therapist outside the metro areas.

How Coverage Works: Four Worked Examples

The four scenarios below are hypothetical illustrations of how Medicare outpatient mental health coverage works for Georgia beneficiaries. The people are composite, and the exact dollars a real family pays depend on their specific plan, provider, and circumstances.

Example 1: Margaret, 78, Atlanta, psychotherapy with an LCSW plus medication management

Margaret is 78, lives in Buckhead, and has traditional Medicare with a Medigap Plan G supplement. Six months ago her husband died after a long illness, and she developed significant depressive symptoms: persistent low mood, anhedonia, sleep disturbance, weight loss, and passive thoughts that life is not worth living (without active planning). Her primary care physician screens her with the PHQ-9 at her annual wellness visit and she scores 18 (moderately severe depression).

Her PCP refers her to a behavioral health team at Emory Healthcare: an LCSW for weekly individual psychotherapy and a geriatric psychiatrist for medication management. The LCSW sees Margaret weekly for cognitive behavioral therapy adapted for grief and late-life depression, billed as CPT 90834 (individual psychotherapy, 45 minutes). LCSWs are paid at 75 percent of the Medicare Physician Fee Schedule rate. Margaret has already met her Part B deductible, so she owes 20 percent coinsurance on the Medicare-approved amount, and Medigap Plan G covers that coinsurance in full. Her out-of-pocket per session is $0.9

The psychiatrist conducts an initial psychiatric diagnostic evaluation with medical services (CPT 90792), then sees Margaret monthly for medication management, billing 99214 (established patient E/M) with the 90833 psychotherapy add-on. Medigap again covers her 20 percent coinsurance. Over six months Margaret completes 24 weekly therapy sessions and 6 psychiatrist visits, and her PHQ-9 drops to 4 (minimal depression). Her out-of-pocket cost for the treatment is $0, because Medigap Plan G covers the cost-sharing entirely; she pays only her monthly Medigap premium.13

Example 2: Robert, 82, Savannah, partial hospitalization on a Medicare Advantage plan

Robert is 82, lives in Savannah, and has a Medicare Advantage HMO plan (no Medigap). After a hip fracture and a prolonged, immobile recovery, he developed major depression with passive suicidal ideation, and his daughter brings him to the Memorial Health emergency department. He is briefly hospitalized in the inpatient psychiatric unit for three days for safety stabilization, then steps down to a partial hospitalization program (PHP) running five days a week, six hours a day, for four weeks. Each PHP day is billed to Medicare as a per-day OPPS rate rather than service by service.8

Because Robert is in Medicare Advantage, his plan sets its own PHP cost-sharing (typically a flat daily copay) rather than the traditional 20 percent coinsurance. What protects him is the federal Medicare Advantage in-network out-of-pocket maximum, which is capped at $9,250 for 2026; once his cumulative in-network cost-sharing for the year reaches that ceiling, the plan pays 100 percent for the rest of the year. Had Robert instead been in traditional Medicare with a Medigap Plan G supplement, his PHP days would have been covered entirely, at $0 out-of-pocket beyond his monthly Medigap premium.9

Example 3: Linda, 75, Macon, intensive outpatient program (the new 2024 benefit)

Linda is 75, lives in Macon, and has traditional Medicare with a Medigap Plan G supplement. Over roughly eighteen months she developed a moderate alcohol use disorder, and she was hospitalized briefly at Atrium Navicent for detoxification after a fall. The discharge plan recommends step-down to an intensive outpatient program (IOP) running three days a week, three hours a day, for a six-week substance-use-recovery curriculum.

Before January 1, 2024, this level of care did not exist as a Medicare benefit: Linda's only options would have been daily PHP (more intensive than she needed) or once-weekly outpatient therapy (not intensive enough for early recovery). Effective January 1, 2024, under Section 4124 of the Consolidated Appropriations Act, 2023 and the new Section 1861(ff)(4), IOP is a covered Medicare benefit, paid under OPPS as a per-day rate. Linda has met her Part B deductible and owes the Part B coinsurance on each IOP day. Because she carries a standard (not high-deductible) Medigap Plan G, the policy covers that coinsurance in full, so her out-of-pocket cost for the entire IOP episode is $0. That is true whether her plan's effective coinsurance rate on a given service is the baseline 20 percent or higher; Plan G covers the Part B coinsurance whatever it comes to.13

Example 4: Patricia, 73, Columbus, inpatient psychiatric admission and the 190-day cap

Patricia is 73, lives in Columbus, and has traditional Medicare with a Medigap Plan G supplement. She has a history of recurrent major depression with two prior inpatient psychiatric hospitalizations (7 days at age 65 and 14 days at age 70, both at a freestanding psychiatric hospital). She now presents to the Piedmont Columbus emergency department with severe depression and active suicidal ideation and is transferred to Anchor Hospital in Atlanta because Piedmont Columbus has no psychiatric unit.

Anchor Hospital is a freestanding psychiatric hospital classified as an Institution for Mental Diseases (IMD), so Patricia's admission counts against her Section 1812(b)(3) 190-day lifetime cap. Her prior admissions used 7 + 14 = 21 days, leaving 169 of her 190 lifetime days. She is admitted for 12 days for stabilization, including electroconvulsive therapy (ECT) for treatment-resistant depression, bringing her lifetime total to 33 days and leaving 157.

Patricia owes the Part A inpatient deductible of $1,736 for the benefit period, which Medigap Plan G covers in full, so her out-of-pocket for the admission is $0. Because she is now a high-utilizer of the non-renewable 190-day cap, she and her family should consider seeking any future psychiatric admissions at a psychiatric unit inside a general hospital (such as Emory Wesley Woods, Memorial Health, or Northeast Georgia Medical Center), where the 190-day cap does not apply.9

Common Mistakes Georgia Beneficiaries and Families Make

Mistake 1: Assuming Medicare doesn't cover mental health

The historic 50 percent coinsurance under former Section 1833(c) (in effect 1965 through 2013) has left a lingering misconception that Medicare provides inferior mental health coverage. Since January 1, 2014, outpatient mental health has been at parity with physical health at 20 percent coinsurance after the Part B deductible. Don't let the legacy 50 percent figure keep you from seeking care.1

Mistake 2: Not knowing your counselor or MFT can now bill Medicare

If your therapist is a Licensed Marriage and Family Therapist (LMFT) or a Licensed Professional Counselor (LPC), Medicare has covered their services since January 1, 2024, provided the therapist has enrolled in Medicare. This is also the fix for couples therapy: CPT 90847 (family psychotherapy with the patient present) is covered, and MFTs do much of the couples and family work that clinical social workers and psychologists historically have not. Ask your therapist whether they have enrolled and accept Medicare assignment before paying out of pocket.

Mistake 3: Missing the new Intensive Outpatient Program (IOP) benefit

Effective January 1, 2024, IOP is a covered Medicare benefit under Section 1861(ff)(4). If you are stepping down from inpatient psychiatric care or a partial hospitalization program, ask the hospital case-management team about IOP options. IOP fills the gap between once-weekly outpatient therapy and daily PHP, and unlike PHP it can be furnished by an FQHC or a rural health clinic, which is often what makes it reachable outside metro Atlanta.

Mistake 4: Not using the free annual depression screening (G0444)

Medicare covers one depression screening every 12 months and waives both the deductible and the coinsurance for it, so it costs nothing when the provider accepts assignment. Two conditions are easy to trip over: the screening has to be furnished in a primary care setting that has staff-assisted supports in place for diagnosis, treatment, and follow-up or referral, and a second screening inside the same 12 months is not covered. Ask your primary care physician about it at your annual wellness visit.4

Mistake 5: Believing Medicare Advantage provides inferior mental health coverage

Medicare Advantage plans must cover everything Original Medicare covers, including every outpatient mental health benefit in this guide, and they must comply with mental health parity requirements. Cost-sharing (copays or percentage coinsurance) may differ from traditional Medicare, and MA plans often add benefits Original Medicare does not have.1

Mistake 6: Not appealing a denied PHP or psychiatric admission

Medicare denials of psychiatric care, including denials of inpatient admission, PHP, IOP, or specific services, are appealable through the five-level Medicare appeals process. The Quality Improvement Organization can also provide immediate advocacy when a beneficiary is discharged from psychiatric inpatient care or PHP too soon.

Mistake 7: Not exploring behavioral health telehealth from home

Behavioral health telehealth is permanent, and geographic and originating-site restrictions have been removed, so you can receive psychotherapy from home, often with the same clinician you would see in person. This is particularly valuable for rural Georgia beneficiaries with limited local provider access. The in-person visit requirement that normally accompanies at-home behavioral telehealth is waived through December 31, 2027.

Where to Get Help in Georgia

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Find personalized help navigating Medicare outpatient mental health coverage in Georgia at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.