Key points
- Part B covers outpatient mental health care, including psychiatric evaluation, medication management and diagnostic tests, from psychiatrists and several other clinician types.
- In 2026 the Part B deductible is $283, after which the patient pays 20 percent of the Medicare-approved amount.
- Medicare pays nothing for services from a clinician who has opted out of Medicare, except in emergencies, so ask about opt-out status before booking.
- The 2026 Part D maximum deductible is $615 and the out-of-pocket cap is $2,100, after which covered drugs cost $0 for the rest of the year.
- As of October 2026 no in-person visit is required before Medicare mental health telehealth at home; that condition is scheduled to apply to services after December 31, 2027.
Medicare covers the same core services a commercial plan would, but its rules on which clinicians you can see, how drugs are covered and how telehealth works are its own. New York's state insurance protections, including the 10-business-day appointment rule, do not apply to Medicare.
The clinical side of a later-life diagnosis is covered in ADHD in adults over 50. This article is about payment.
Part B: evaluation and follow-up visits
Medicare Part B covers outpatient mental health care. Medicare lists psychiatric evaluation, medication management and diagnostic tests among covered services, and it covers them when provided by psychiatrists and other doctors, clinical psychologists, nurse practitioners, physician assistants, clinical social workers and certain other professionals.
After you meet the Part B deductible, you pay 20 percent of the Medicare-approved amount. Visits at a hospital outpatient clinic may carry an added facility copayment.
| 2026 figure | Amount |
|---|---|
| Part B deductible | $283 |
| Standard Part B premium | $202.90 per month |
| Your share after the deductible | 20% of the Medicare-approved amount |
To give a sense of scale, the 2026 approved amount for a psychiatric diagnostic evaluation with medical services (CPT 90792) in Manhattan, calculated from CMS fee schedule files, is about $224, so the 20 percent share is about $45. For a 30-minute follow-up visit (CPT 99214) it is about $153, or about $31 for the patient. Outside the New York City area the amounts are somewhat lower. These are illustrations from the fee schedule, not quotes from any practice.
A Medigap policy may pay some or all of the 20 percent. A Medicare Advantage plan replaces this structure with its own copays and its own network.
Which clinicians you can see
Medicare sorts clinicians into three groups, and the difference is large.
| Clinician status | What you pay |
|---|---|
| Accepts assignment | The deductible and coinsurance only. |
| Non-participating | May charge more than the approved amount. Medicare says that in many cases the charge cannot be more than 15 percent above it. The clinician should submit the claim. |
| Opted out | The full fee under a private contract. Medicare states it will not pay for items or services from a provider who opts out, except in emergencies. |
With an opted-out psychiatrist you cannot send a receipt to Medicare and get part of it back. If you have original Medicare and are considering a private-practice psychiatrist, ask directly: Have you opted out of Medicare? For this practice, see the fees and insurance page.
If you have a Medicare Advantage plan, ask the plan whether the psychiatrist is in its network and what, if anything, it pays outside the network.
Part D: ADHD medication
Prescription drugs you take at home are covered under Part D, either through a stand-alone drug plan or through a Medicare Advantage plan with drug coverage.
| 2026 Part D figure | Amount |
|---|---|
| Maximum deductible a plan may set | $615 |
| Out-of-pocket cap | $2,100, then $0 for covered drugs for the rest of the year |
The optional Medicare Prescription Payment Plan lets you spread out-of-pocket drug costs across the year in monthly payments.
Each Part D plan has its own formulary. Whether a given ADHD medication is on it, on which tier, and whether the plan asks for prior authorization or sets a quantity limit, differs from plan to plan. One insurer's Part D bulletin, for example, describes requiring a valid diagnosis before paying for amphetamine, methylphenidate and lisdexamfetamine products. A general CMS statement on how plans must treat stimulants was not confirmed for this article, so the dependable step is to check your own plan.
Medicare's Open Enrollment Period runs from October 15 to December 7 each year, with changes taking effect January 1. During that window, enter your exact medication and pharmacy in the plan comparison tool on medicare.gov and look at the full-year cost, not only the premium. Wider ways to reduce drug costs are in what ADHD medication costs in New York.
Telehealth: what is permanent and what is delayed
Two different things are often reported as one.
Location. Through December 31, 2027, Medicare beneficiaries can receive telehealth services anywhere in the United States, including at home. From January 1, 2028 the older geographic and facility limits return for most services, except for behavioral health services. Mental health telehealth at home is a permanent benefit.
The in-person condition. The statute attaches a condition to mental health telehealth at home: an in-person, non-telehealth visit within the 6 months before the first telehealth service, and then an in-person visit within 12 months of each later one, with limited exceptions. That condition has been delayed. According to the CMS telehealth FAQ updated October 8, 2026, it now applies to services after December 31, 2027.
| Question | Status as of October 2026 |
|---|---|
| Is an in-person visit required before a Medicare telepsychiatry visit today? | No. |
| Has the requirement been repealed? | No. It is delayed and scheduled to start January 1, 2028 unless Congress acts again. |
| What if I start telehealth before then? | A beneficiary who began mental health telehealth at home on or before December 31, 2027 is treated as established: no 6-month look-back visit, but an in-person visit at least every 12 months after that date. |
| Who can do the in-person visit? | If the treating clinician is unavailable, a clinician of the same specialty in the same group practice may. |
| Audio-only visits? | Allowed at home through December 31, 2027. Afterward, still allowed for behavioral health at home when the clinician can do video but the patient cannot or does not consent to it. |
The delay comes from the Consolidated Appropriations Act, 2026. CMS proposed matching regulations in its 2027 physician fee schedule proposed rule in July 2026. Whether the final version of that rule had been published was not confirmed at the time of writing, so check the CMS telehealth page for the current position.
Questions to settle before your first visit
- Do I have original Medicare or a Medicare Advantage plan?
- Does the clinician accept assignment, or have they opted out?
- Have I met this year's Part B deductible?
- Do I have Medigap or other secondary coverage for the 20 percent?
- Is my medication on my Part D formulary, and does it need prior authorization?
- If I plan to use video visits, how will the in-person visit be handled once the 2028 rule starts?
How this practice schedules video and in-person visits is described on the appointments and telehealth page.
Questions
Does Medicare cover an ADHD evaluation for an older adult?
Part B covers outpatient psychiatric evaluation and diagnostic tests as mental health care. After the Part B deductible you pay 20 percent of the Medicare-approved amount when the clinician accepts Medicare. Medicare's page does not single out ADHD; the evaluation is billed as an ordinary psychiatric service.
Can I get reimbursed by Medicare if my psychiatrist has opted out?
No. Medicare states that it will not pay for services from a provider who has opted out, except in emergencies. You would pay the full fee under a private contract.
Does Medicare Part D cover stimulant medication?
Coverage depends on the plan's formulary. Plans differ on which products are listed, the tier, and whether prior authorization or quantity limits apply. Check your specific medication in the plan finder on medicare.gov during Open Enrollment, October 15 to December 7.
Do I need an in-person visit before seeing a psychiatrist by video on Medicare in 2026?
No. The in-person condition for mental health telehealth at home is delayed and applies to services after December 31, 2027, according to the CMS telehealth FAQ updated October 8, 2026. It has not been repealed.
Does New York's 10-business-day appointment rule apply to Medicare?
No. That rule covers New York-regulated commercial policies, Medicaid Managed Care, the Essential Plan and Child Health Plus. Medicare follows federal rules.
Sources
- Medicare.gov: Mental health care (outpatient)
- CMS: 2026 Medicare Parts B premiums and deductibles (November 14, 2025)
- Medicare.gov: Does your provider accept Medicare as full payment?
- Medicare.gov: Part D costs
- Medicare.gov: Joining a plan (Open Enrollment Period)
- CMS: Telehealth FAQ (updated October 8, 2026)
- CMS: CY 2027 Medicare Physician Fee Schedule proposed rule fact sheet (July 14, 2026)
- CMS: Physician Fee Schedule relative value files, RVU26D (August 26, 2026)
- NYS Department of Health and Department of Financial Services: Network adequacy consumer fact sheet (July 1, 2025)
