Is transcranial magnetic stimulation covered by medicare

Is TMS covered by Medicare?

One of the most frequently asked questions we receive would have to be, is TMS covered by Medicare? At this very moment the short answer to this question is no. However, this is all about to change. As from 1 November a new medicare item number will be available as part of the governments commitment to mental health. In the past, TMS costs have not been covered under medicare and very few health insurance companies have provided benefits. Unfortunately not everyone will benefit from the changes coming in on 1 November 2021. 

Medicare

Medicare funds medical treatment outside of hospital. This includes outpatient care that you would receive from your GP or psychiatrist. For such visits to the doctor medicare will contribute to the funding. As TMS is an outpatient treatment, the obvious fund provider would be Medicare. The College of Psychiatrists in Australia (RANZCP), are currently working on Medicare funding for TMS treatment. Several submissions have been made and we are waiting on the latest response. A result to the latest submission is due in the second half of 2019. We are looking forward to some positive news in the upcoming months. We recommend that you keep visiting our website for updates.

There are other forms of funding that individuals can apply for. They include: Defence forces funding, Workcover and Private Health Insurance cover. In some cases individuals are being sponsored by employers to receive TMS treatment.

Funding options

If you are keen to find out more about payment plans to assist you with receiving TMS treatment please contact us. Our TMS consultants can provide you with some options that may help you.

TMS is playing an important role in treating depression.

TMS has the support of hundreds of research studies showing its effectiveness in treating depression. For patients where previous treatments have not worked many people do not have a lot of choice. Antidepressant medication is not effective for everyone. For many, the side effects prevent people from continuing on with medication treatment. In the past, when antidepressant medication has failed those with severe depression have very few options. Electroconvulsive (ECT) therapy is often the next option for those with severe symptoms. The side effects of ECT are significant for patients. TMS plays a vital role for clinicians as it fills the gap between medication and ECT.

For more information about TMS please visit our website sydneytms.com.au

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By Dr. David Woo - November 3, 2020

Yes! Medicare covers TMS therapy in New York.

While Medicaid doesn’t yet cover TMS, Medicare does. Patients who are eligible for Medicare include US citizens who are 65 years and older, or who are severely disabled. Income is not a deciding factor for Medicare eligibility. To learn more about Medicare eligibility and enrollment, visit the Centers for Medicare and Medicaid website. 

Who Qualifies to Have TMS Treatment Covered by Medicare?

Patients who are eligible to use their Medicare benefits to cover the cost of TMS therapy must be diagnosed with major depressive disorder (MDD). TMS must be prescribed and administered by a Medicare-approved physician with experience in providing TMS (like Dr. Woo at Madison Ave TMS & Psychiatry). (1) Patients must also meet at least one of the following criteria:

• Treatment resistance: Medicare requires patients to try 4 antidepressants from at least 2 different classes. If patients do not show a significant clinical response after trying 4 antidepressants, they are considered treatment-resistant. 

• Intolerance to antidepressant medications: This includes patients who are unable to take antidepressants due to health reasons, such as bleeding disorders, or patients who had a difficult time handling the side effects of the antidepressants they tried (the patient needs to have tried 4 different antidepressants from 2 different drug classes). 

• History of response to TMS: Patients who have previously shown a significant clinical response with TMS during a previous depressive episode may be able to get coverage for TMS without having to try more medication. (1) 

How Much of the Cost of TMS Therapy Does Medicare Cover?

In New York State, Medicare covers 80% of the cost of TMS therapy for the treatment of depression. Patients are responsible for paying their annual deductible and their monthly premiums, and 20% of the treatment cost. Patients who have secondary insurance oftentimes pay less than 20%, and may even pay nothing at all. (1) Learn more about TMS therapy costs here.

Madison Ave TMS & Psychiatry Accepts All Major Insurance Plans That Offer Coverage for TMS

In addition to accepting Medicare, we also accept all major insurance plans that cover costs associated with TMS. See which insurance plans we accept.

If we are out-of-network for your insurance plan, we can negotiate directly with your insurance company to partially or fully cover the costs of TMS. To ask us about coverage for TMS treatment with an out-of-network provider, please call our office at 212.731.2033. 

If you’re not sure if your insurance plan covers TMS, call your insurance company. A representative or an advisor can help you understand your insurance coverage. The questions you’ll want to ask are:

• Does my insurance plan cover TMS?
• Is TMS covered fully or partially?
• Do I need pre-approval to be covered for TMS?

Learn more about insurance coverage for TMS here. 

Resources:

1. Transcranial Magnetic Stimulation. Centers for Medicare and Medicaid Services. Published October 01, 2015. Updated October 01, 2020. https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33398&ver=26&keyword=tms&keywordType=starts&areaId=s63&docType=NCA,CAL,NCD,MEDCAC,TA,MCD,6,3,5,1,F,P&contractOption=all&sortBy=relevance&bc=AAAAAAQAAAAA&KeyWordLookUp=Doc&KeyWordSearchType=Exact. Accessed October 20, 2020. 

Dr. Woo has been seeing patients in private practice since 2002, always with the goals of combining evidence-based medicine with psychodynamic psychotherapy and collaborating with other mental health professionals to ensure the best possible outcomes for his patients. He has been certified to administer TMS at his practice since 2017. His greatest clinical interests include helping patients suffering from depression, anxiety, and obsessive compulsive disorder.