Is TMS Covered by Insurance?

Is TMS Covered by Insurance?

Is TMS Covered by Insurance?

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Author: GIA Miami
Published: December 27, 2022

TMS or transcranial magnetic stimulation is an evidence based, well proven and FDA approved treatment therapy. TMS uses gentle magnetic pulses to stimulate the brain, helping to better regulate mood in patients with depression, OCD and many other mental health illnesses.

TMS was first approved by the FDA (Food and Drug Administration Agency) in 2013 for the treatment of major depression. FDA approval followed for OCD ( obsessive compulsive disorder ) in 2017 and "anxious depression" in 2021 As time passes, doctors are understanding more and more about the treatment. TMS is now being used to treat other psychological and medical conditions such as PTSD, cravings related to additions, Long Covid Symptoms, cognitive enhancement and sleep difficulties.

Do I Need TMS Treatment?

If you aren't sure if TMS is right for you, the first step to finding out is to speak to your doctor. Your doctor will be able to analyze your condition and symptoms and tell you whether TMS is the best method of treatment or whether other medically necessary services should be tried first. Common indicators that TMS would benefit you are:

  • Severe major depressive disorder
  • Bipolar disorder
  • OCD Obsessive Compulsive Disorder
  • Medical records indicate that other forms of treatment have failed, leading to treatment-resistant depression.
  • Medical history of previous TMS use and success
  • Chronic pain

Common factors that disqualify people from TMS and indicate a preference for other treatment options are:

  • Pregnancy
  • Epilepsy
  • Seizure disorders
  • Suicide ongoing substance abuse-related neurological issues
  • Using cochlear implants
Am I Covered?

Am I Covered?

While TMS became FDA-approved for adult patients for the first time in 2013 as a treatment for severe major depressive disorder and is being approved now for other mental health treatments such as OCD just this year, whether or TMS therapy coverage is included in your coverage policies is a different matter. Most insurance companies don't have a yes or no answer for whether they will cover TMS treatment, and whether the insurance will cover TMS therapy depends on numerous complicating factors.

For your insurer to cover TMS therapy for the treatment of major depressive disorder (MDD), it is most likely that you will need to have tried at least two medications, such as SSRIs, SNRIs, and atypical anti-depressants for a full treatment course along with talk therapy sessions for a certain period without seeing any significant progress in the relief of the symptoms of the condition.

Accurate treatment records are usually needed to prove this in order to qualify for funder care. A mental health professional may be much more likely to recommend TMS for treatment-resistant depression. Demonstrating that talk therapy and medication have already been tried unsuccessfully means the likelihood that an insurance company approves coverage is much higher.

Certain complicating factors may disqualify patients from being covered by most major insurance companies, however, most insurance companies cover what is in line with medical recommendations for when TMS therapy is the apt treatment to use.

Pregnancy, seizures, suicidal thoughts, or metal in the cranium can disqualify you for cover for TMS treatment, however, these are all contraindications that would direct medical professionals away from TMS treatment in the first place.

How Much Does TMS Therapy Cost?

TMS treatment usually has sliding scale pay options but a typical session's full price is approximately $300. In order to get good results multiple sessions are required and a course of treatment will usually be something between $6000 to $12000 plus consultation fees before you begin treatment.

Is TMS Therapy Covered by Medicare?

Yes, but there are certain criteria for TMS coverage.

In order for Medicare to cover the cost of your TMS therapy, you need to meet the following conditions.

  • Be diagnosed with major depressive disorder by a Medicare-approved physician or mental health professional.
  • Be able to prove that medications have been used to attempt to treat the condition and that they have failed
  • Or, be able to show that you can't take medication due to other health conditions or medications that are being taken at the time.

If you are unsure of whether your claim will be accepted by Medicare you could also contact local government benefit administrators for help.

Does Medicaid Cover TMS?

Medicaid is another of the national government services but is less like to cover TMS therapy than Medicare, the state you live in heavily influences this. Instead of reading about it here, you should contact them directly with details of your situation to ask for more details on insurance coverage. At the time of writing this article, Medicaid doesn't cover TMS therapy in Florida state.

Do Independent Companies Cover TMS?

Do Independent Companies Cover TMS?

Every company is different as to whether or not they will or won't cover TMS and in which circumstances, however, based on our research, here are some of the best options to go for if you want to have TMS therapy as an option:

  • Blue Cross Blue Shield, including Hawaii Medical Services Association
  • AETNA
  • United Healthcare

How Much Will I Pay?

Exactly what percentage of the treatment the insurance company will cover depends on the policy itself, the overall cost, and your insurance coverage. American insurance policies use out-of-pocket deductibles, copay, coinsurance, and out-of-pocket maximums to calculate your level of contribution, and these are included in the insurance company's cover.

Deductible- This is the amount you will have to pay each year before you can expect any financial contribution from the insurance company whatsoever. This figure will vary depending on your policy and the insurance provider. For example, if the deductible amount in the health care plan is $2,000 and the TMS treatment will cost $10,000 altogether, you will have to pay the first $2,000 with no help from the insurance provider whatsoever.

Copay- These are fixed amounts that you are expected to pay for certain services before receiving help from your insurance provider. You may be likely to have a copay charge for the initial consultation, and any prescription drugs tried before TMS therapy is suggested as a viable treatment.

Coinsurance- After the deductible part of an insurance plan, the insurance company will split the costs of treatment with the patient at a certain percentage until they reach the out-of-pocket maximum. For example, if the co-insurance stipulates 20/80 with the insurer paying 80% after the deductible limit has been met, and the total costs for TMS were $8,000 with a deductible of $2,000. You would have to pay 20% of the $6000 left after the deductible limit had been met. 20%of $6,000 being ($1,200) would leave a total fee of $3,200.

Out-of-pocket maximum- Most insurance policies have out-of-pocket maximums much higher than the cost of TMS therapy however, if this limit were to be reached, you would no longer be eligible for financial help and would need to cover any further costs yourself.

Other Sources of Funding

Suppose you don't have insurance or are unable to pay for the out-of-pocket part of the treatment. In that case, there are various medical financing programs, such as medical loans, that can provide you with a source of funding and make treatment accessible.

Medical loans- Medical loans are personal loans given to you so that you can pay your medical bills when savings and family help aren't enough.

How to Contact My Insurance Company About Coverage.

Speaking to a benefits administrator or your insurance company directly about TMS coverage is strongly recommended before scheduling TMS sessions. Insurance providers will be able to tell you whether you can receive TMS treatment on your policy. If they don't offer TMS coverage, they can inform you of which treatment options they do cover medically. Once again, they may ask you to exhaust other options, such as therapy appointments, if you are initially denied coverage for TMS.

It is important to be honest with insurance providers and have accurate treatment records available to fight your case for TMS coverage, making claims about things such as chronic pain without having the medical records to prove so may go against you, major insurance companies require evidence to prove liability for TMS therapy coverage.

If you are interested in receiving TMS treatment to help your mental health condition but are worried about insurance policy coverage, nursing acute risk, whether it's right for you, the costs involved, and whether your insurance policy will cover it, give us a call now at 813 713 0828. We are available 24/7 and our expert care team will guide you down the right path to ensure your needs are met at the most affordable price possible.

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