Deep TMS helps people with severe depression and other conditions manage their symptoms. Learn more about insurance coverage for deep TMS at Sun Health Center.
Transcranial magnetic stimulation (TMS) uses magnetic fields to stimulate brain cells, improving communication within the nervous system. The deep version uses a different coil, allowing the magnetic fields to penetrate deeper and affect a larger region of the brain. This technique is FDA-approved for obsessive compulsive disorder (OCD), and it’s also used to help people with treatment-resistant depression. Deep TMS has even demonstrated benefits for patients wanting to quit smoking.
If you have any of these conditions, it’s natural to wonder whether insurance covers deep TMS. The answer depends on many factors, such as which insurer you use, what type of plan you have and whether you’ve already met your deductible for the year.
At Sun Health Center, we’re committed to making mental health treatment accessible to as many people as possible. We’ll help you determine what your plan covers and how you can use your benefits to begin your recovery.
Insurance Coverage for Deep TMS Services
Insurance can make deep TMS significantly more affordable, but coverage isn’t universal. Whether you can use your insurance benefits to pay for transcranial magnetic stimulation depends on these factors:
- Insurance company
- Plan details
- Diagnosis
If your plan covers deep TMS, you still need to meet your insurer’s medical necessity criteria. A service is medically necessary if your condition will get worse or you’ll remain in a significantly worsened state if you don’t get it. For example, you may be able to meet the medical necessity criteria by demonstrating that your depression symptoms have gotten so severe that you’re unable to work full-time.
Many plans also require prior authorization, which involves having your treatment provider submit records documenting your diagnosis and previous treatments. For major depressive disorder (MDD), you may have to show that antidepressants and other standard treatments haven’t helped.
Even if your plan covers deep TMS, you may have some out-of-pocket expenses:
- Deductible: The amount of money you have to pay before your insurance covers anything
- Copay: A flat fee paid for each session
- Coinsurance: A percentage of the approved amount (e.g. 20% of a $500 charge)
Private Insurance Companies
Many private insurers cover deep TMS for members meeting the medical necessity criteria. However, just because your insurance company pays for deep TMS doesn’t mean your individual plan does. It’s critical that you check your Summary of Benefits and Coverage or your member handbook to determine exactly what your plan covers.
Coverage rules can vary significantly from one plan to the next, even when both plans are administered by the same insurance company. For example, one plan may pay for deep TMS if you’re able to prove that other treatments haven’t worked. Others may not cover it at all.
Medicare and Medicaid Coverage
Medicare may pay for deep TMS when it’s used for treatment-resistant depression. However, it depends on what type of Medicare you have and which Medicare Administrative Contractor processes your claims. For example, Novitas covers TMS for Medicare beneficiaries who’ve been diagnosed with major depressive disorder and failed at least one antidepressant medication.
For Medicaid, coverage varies significantly, as each state manages its own program. Some states even have Medicaid managed care, which is when a private insurance company coordinates care for residents with Medicaid coverage. The purpose of Medicaid managed care is to reduce costs, so your plan may not cover deep TMS or other non-medication treatments.
How to Check Your Insurer’s Deep TMS Benefits
To determine if your insurer covers deep TMS, read your Summary of Benefits and Coverage. This document provides an overview of your plan details, such as what’s covered and how much you have to pay out of pocket for each service.
If you can’t find TMS information in the summary document, contact your insurance company directly. Be prepared to provide your member ID, group number and other relevant details. The insurance representative may ask questions about your diagnosis and past treatment to determine if you’re covered.
The easiest way to determine if deep TMS is covered is to have Sun Health Center verify your benefits. If you provide your name, member ID and group number, we can find out if your plan covers deep TMS and other treatments for major depressive disorder or OCD.
Frequently Asked Questions
Do I have to pay a deductible for deep TMS sessions?
It depends on your insurance plan. In insurance terms, a deductible is the amount of money you have to pay before your insurer starts covering any of your medical expenses. Some plans have no deductible, while others have deductibles exceeding $3,000. The best way to determine your potential out-of-pocket costs is to verify your benefits before you begin treatment.
What if Sun Health Center isn’t in my insurance network?
Just because SHC isn’t in your network doesn’t mean you’re out of options. Some plans include out-of-network coverage, which allows you to seek care from facilities that haven’t contracted with your insurance company. If your plan is one of them, you may still be able to use your insurance to pay for deep TMS at Sun Health Center.
What conditions does insurance cover deep TMS for?
Coverage varies based on insurance company and plan, but major depressive disorder is one of the most common covered conditions, especially if you’ve tried other treatments without success. Your plan may also cover deep TMS for obsessive compulsive disorder (OCD) or depression with co-occurring anxiety.
Do I need prior authorization for deep TMS?
It depends on your plan’s requirements. If your insurer requires prior authorization, one of our staff members will submit the paperwork and let you know if it’s approved.
What happens if my insurer denies coverage for deep TMS?
If your plan doesn’t cover TMS, you have other options. Some people pay out of pocket for deep TMS and use their insurance for covered services. For those with financial constraints, we may be able to recommend an insurance-approved alternative to deep TMS.
Starting Treatment at Sun Health Center
Health insurance can be complicated, but Sun Health Center has experienced professionals available to verify your benefits and help you understand what’s covered. If you’ve been struggling with treatment-resistant depression, OCD or depression paired with anxiety, we can develop a personalized treatment plan that includes TMS, therapy and other techniques.
You deserve compassion and support as you begin your mental health recovery. Contact Sun Health Center today to speak with one of our counselors any time day or night.
