Partial hospitalization (PHP), an intensive outpatient program to treat substance misuse or mental health conditions, is covered by Medicare in certain circumstances.
Partial hospitalization is a mental health treatment program that can help you recover without a hospital stay.
This service is an outpatient treatment, so you’ll sleep in your own home every night. During the day, you’ll receive intensive therapy under the care of licensed professionals.
Medicare will provide coverage if you need this level of care, although your costs will vary depending on your Medicare plan and the facility where you receive treatment.
Partial hospitalization is an outpatient treatment program for people in recovery from substance misuse or mental health conditions. It’s an alternative to an inpatient hospital stay.
During partial hospitalization, you’ll travel to a hospital outpatient center or other facilities for structured treatment during the day but will go home in the evenings. This treatment is much more intensive than standard outpatient treatments.
Partial hospitalization includes a number of structured treatments, such as:
- a care plan for your recovery
- individual therapy
- group therapy
- occupational therapy
- other therapies, including art and music therapy
- education to help you in your recovery
- family counseling related to your reason for being referred to partial hospitalization
The goal of this program is to help you get well enough that you no longer need that level of care.
During your treatment, you’ll be under the care of licensed professionals.
They’ll evaluate your progress and help you prepare to leave the program. They might also prescribe medications that can help you meet your treatment goals.
Medicare will cover partial hospitalization as long as it meets specific requirements. To be covered, you’ll need to:
- receive your care at a Medicare-approved facility
- receive your care under the supervision of a licensed physician
- have a doctor certify that standard outpatient therapy wouldn’t be enough to help you avoid being admitted to the hospital
- have a doctor certify that you’d need inpatient hospital care if you didn’t participate in a partial hospitalization program or if you’ve recently been discharged from an inpatient hospital stay and need additional support
If your partial hospitalization meets these requirements, Medicare will cover it.
Your Medicare coverage will include all the necessary treatments that are part of the program. However, it won’t include extra services like transportation to and from the program.
Partial hospitalization is outpatient care. When you use Medicare parts A and B, also known as Original Medicare, your coverage will come from Part B.
That’s because Part A is hospital insurance. It only covers inpatient care in hospitals, skilled nursing facilities, and other settings.
Part B is medical insurance. It will cover your outpatient care, including partial hospitalization.
Original Medicare isn’t your only coverage choice.
All Medicare Part C (Medicare Advantage) plans are required to cover the same services as Original Medicare. This means that any Medicare Advantage plan will also cover partial hospitalization.
Plus, Medicare Advantage plans also often include coverage for services beyond what Original Medicare covers, like dental or vision care, so they might cover even more of your costs.
Any prescriptions administered to you while you’re at the facility of your partial hospitalization program will be covered under Medicare Part B or your Medicare Advantage plan.
If you need to take any prescriptions at home, you’ll need a separate prescription drug plan. Many Medicare Advantage plans include prescription drug coverage.
If you’re using Original Medicare, you can add a Medicare Part D plan. Medicare Part D is stand-alone prescription coverage that covers any prescriptions you need to take at home.
A Medicare supplement (Medigap) plan can also help cover some of your treatment. Medigap plans help you cover the out-of-pocket costs of using Original Medicare, such as copayments and deductibles.
They don’t offer additional coverage. However, they can reduce the cost of a partial hospitalization program for you.
The cost of partial hospitalization depends on the type of treatment you need, the facility you use, and more.
Searching the cost at facilities around the country shows that programs can cost from a few hundred up to a few thousand dollars per day without insurance of any kind. Your Medicare coverage can reduce those costs significantly.
When you use Medicare Part B, you’ll first need to meet your yearly deductible. In 2024, the deductible is $240. Once you meet the deductible, you’ll pay a coinsurance of 20% of the Medicare-approved cost of your treatment, and Medicare will pay the other 80%.
The Medicare-approved amount is a set amount for treatment that a facility has agreed to accept from Medicare as payments.
It’s often lower than the price you’d pay without insurance. So, not only are you only responsible for 20%, you’re responsible for 20% of a lower total amount.
A Medigap plan can lower these costs even further. Medigap plans can cover the cost of your coinsurance. You’ll pay an additional monthly premium for a Medigap plan, but you won’t have out-of-pocket costs for your treatment.
Your cost in a Medicare Advantage plan will depend on the plan. Medicare Advantage plans set their own costs, including deductibles and copayment amounts. If you’re not sure, check the details of your plan.
Your doctor will recommend partial hospitalization to you if you’re eligible. Generally, referrals to this type of program are triggered by mental health events such as periods of self-harm or by substance misuse events like an overdose.
Many people are referred to a partial hospitalization program after an event that hospitalizes them.
Even without a recent hospital stay, you might be a candidate for a partial hospitalization program if you’re having trouble functioning independently and need support to get back on your feet.
If you’re living with addiction or a mental health condition, tell your doctor. They’ll be able to recommend the right course of treatment for you. If that includes partial hospitalization, they can make a referral.
When to seek help for your mental healthReach out for help with your mental health if you:
- have had thoughts of suicide or self-harm
- have been feeling depressed for weeks with no change
- feel hopeless
- are losing interest in the things you usually enjoy
- are no longer able to focus at work, school, or home
- have strong, overwhelming feelings of panic
- have been avoiding people or places that cause panic
- experience thoughts that no longer feel like your own
- have had thoughts of harming others
- are experiencing excessive anger or sudden shifts in mood
Partial hospitalization can help you recover from substance misuse or mental health conditions. You can get the treatment and support you need to get better without staying overnight in a hospital.
Medicare will pay for this service as long as it meets the criteria. Generally, this means the program needs to be recommended by a doctor and must be from a Medicare-approved facility.
Your costs will depend on your Medicare plan and your treatment.