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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.
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.
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