How to verify your Medicare mental health benefits.
Original Medicare (Parts A and B) covers outpatient mental health services — therapy, psychiatry, medication management, and FDA-approved TMS for treatment-resistant depression. There's no referral required, the deductible is the standard Part B deductible, and Medicare pays 80% of the approved amount with the remaining 20% as your responsibility unless you have a Medigap supplement. The verification call is short because Medicare's behavioral-health coverage is essentially universal across the program — what you're confirming is the deductible status, any Medicare Advantage plan rules if you have one, and the Part B copay for the specific service. Positive Reset Eatontown accepts Original Medicare and several Medicare Advantage plans.
The call, in order.
Total time: about 10 minutes for most plans, 24 hours if the rep has to call back.
Identify your Medicare type
Look at your card. If it says 'Medicare' and lists Part A and Part B, you have Original Medicare — the federal program directly. If it says a private insurer's name (Aetna Medicare, UHC AARP, Humana Medicare Advantage, Cigna Healthspring, etc.), you have a Medicare Advantage plan, which is administered by that insurer under contract with CMS. The verification path differs by type.
For Original Medicare: confirm coverage
Call 1-800-MEDICARE (1-800-633-4227) or use the online Medicare Coverage tool. Original Medicare covers outpatient mental health at 80% after the Part B deductible. There is no PCP referral required. Confirm your Part B deductible status for the current calendar year — once met, the 20% coinsurance applies until any out-of-pocket maximum.
For Medicare Advantage: call the private insurer
Use the member services number on the back of your Medicare Advantage card, not 1-800-MEDICARE. Medicare Advantage plans must cover everything Original Medicare covers but can structure copays differently (often a flat per-visit fee, sometimes lower than the Part B coinsurance). Confirm we are in-network with your specific Medicare Advantage plan.
Confirm the visit-type copay
Ask specifically about the copay for therapy visits, psychiatry visits, and medication management visits — they can differ slightly. For Original Medicare, the answer is 20% of the approved amount after the Part B deductible. For Medicare Advantage, it's typically a flat dollar amount that varies by plan.
Confirm Medigap supplement coverage (if applicable)
If you have Medigap (Plan G, Plan N, Plan F, etc.), your supplement typically pays the 20% coinsurance that Original Medicare doesn't cover. Confirm with your Medigap insurer that outpatient mental health is part of your supplement. Most Medigap plans do not require separate prior authorization.
Confirm telehealth and TMS coverage
The 2022 Consolidated Appropriations Act made telehealth permanent for Medicare behavioral health, and we deliver telehealth across all of New Jersey. TMS for treatment-resistant depression is covered under Part B with documentation of two or more antidepressant trials at adequate dose and duration. Annual depression screening is covered at no cost as a preventive service with no deductible applied.
Exactly what to ask the rep.
Copy this list before the call. Each item is the kind of answer that should be on the line with you, not in a follow-up email a week later.
- Is Positive Reset Eatontown in-network under my Medicare plan?
- Has the Part B deductible been met for this calendar year?
- What is the copay or coinsurance per visit?
- If I have Medigap, what does the supplement cover?
- Is no-cost annual depression screening included?
- Is telehealth covered for behavioral health?
- What's the documentation requirement if I need TMS later?
Plan-specific notes.
A 2024 Medicare expansion newly allows licensed marriage and family therapists (LMFTs) and licensed mental health counselors (LMHCs) to bill Medicare directly, which broadened access at our clinic. If you have been told in the past that your preferred clinician couldn't see you under Medicare, that may no longer be true — ask us on the verification call.
No PCP referral is required for outpatient mental health under Original Medicare or any Medicare Advantage plan. An annual depression screening is covered at no cost as a preventive service, with no Part B deductible applied. If you've never used your annual screening, it's worth scheduling — even if the result is negative, the screening counts as preventive care and gets you in the door without a copay.
For Medicare Advantage plans, the carrier sets the operational rules on top of the federal floor. Common Medicare Advantage plans in New Jersey include Aetna Medicare, UnitedHealthcare AARP, Humana, Cigna Healthspring, and Wellcare. Verify your specific plan; we accept several but not all.
We can run the verification for you.
Call us with your member ID and we’ll do the verification call ourselves — usually 5–10 minutes for most plans, 24 hours for plans that require a callback. You’ll get the copay and coverage answer before you book your first visit.
See the full Medicare coverage page for what we treat and what’s covered.
Other things people ask.
Do you accept Medicare?
Yes. We accept Original Medicare (Parts A and B) for outpatient mental health, including therapy and psychiatry. We also accept several Medicare Advantage plans — call us at (732) 724-1234 with the name of your specific Medicare Advantage plan and we'll verify in-network status before you book.Do I need a referral from my primary care doctor?
For most plans, no. Commercial plans like Aetna, Cigna, Horizon BCBS, Oxford, and UnitedHealthcare typically don't require a referral for outpatient mental health. Some Medicare Advantage plans do. NJ FamilyCare doesn't require a referral for outpatient therapy or psychiatry. We tell you up front if your specific plan needs one.How much will therapy cost me?
If you're insured and we're in-network, you typically pay only your plan's copay or coinsurance — usually $0 to $40 per visit. NJ FamilyCare members pay $0. Self-pay rates start at $125 for medication management and $150 for individual therapy. We tell you the exact cost before your first visit, per the No Surprises Act.
Last updated: 2026-05-23