Is Ketamine Therapy Covered by Insurance?

For many struggling with challenging mental health conditions and their symptoms, ketamine therapy is proving to be a breakthrough treatment option. 

While ketamine therapy is increasingly considered a game-changer for those seeking new mental health treatment options, it’s not officially covered by a majority of insurance companies in the United States.

The U.S. is currently experiencing a major mental health crisis. In 2020, one in five adult Americans experienced mental illness. This means tens of millions of Americans live with anxiety, depression, and other potentially debilitating conditions.

Enabling healthcare coverage for emerging mental health treatments such as ketamine therapy —including through Medicare and Medicaid programs— is a critical step in increasing access to those millions of Americans.

Why Generic Ketamine Isn’t Currently Covered by (Most) Insurance Companies

Lack of insurance coverage for ketamine therapy could be due to any number of factors. 

Insurance companies may not cover ketamine therapy because it is prescribed “off-label.” Ketamine was approved by the FDA in 1970 as an anesthetic, and has been used to treat mental health conditions for more than 20 years.

Esketamine, an intranasal ketamine-derivative spray under the brand name Spravato, was approved by the FDA in 2019 for patients with treatment-resistant depression. However, even coverage of Spravato varies based on the type of insurance you may have.

Because generic ketamine has not been approved by the FDA specifically for treatment of depression and anxiety, some insurers choose not to cover it. Fortunately, research is currently advancing multiple psychedelic medicines, toward FDA approval. This includes generic ketamine’s application in treating a number of conditions.

How to Determine if Ketamine is Covered by Your Insurance Provider

Even if coverage of ketamine treatment is limited, there are still options to help determine if your insurance provider will cover or help offset costs of ketamine treatment.

1. Check with your insurance provider first

Before starting ketamine therapy, it’s best to first check with your insurance provider to see if they provide any type of coverage to help subsidize or cover the full cost of ketamine treatment. 

Though insurance coverage for ketamine therapy is case-by-case, there are some insurance providers that are willing to cover some up-front costs of ketamine treatment —for example, by designating the treatment “an infusion of a generic drug.” It’s always helpful to discuss these possibilities with an insurance representative ahead of time.

After receiving care, your insurance provider will send an “explanation of benefits,” which details the costs of treatment and how much insurance will cover. In some cases, you’ll need to meet your deductible before the insurance provider will provide full or partial coverage of the cost of any services.

2. Ask about out-of-network reimbursement

In some cases, your insurance provider will ask you to pay your clinical provider “out-of-pocket,” or using your own finances, with the intent of reimbursing you. This is known as “out-of-network” reimbursement.

Unless expressly stated as part of your terms of agreement, most insurance providers will accept out-of-network claims for healthcare services. How these claims are paid or reimbursed is unique to each insurance provider. Depending on your coverage, you may receive a full or partial reimbursement for those services in the following weeks.

Again, it’s important to check with your insurance provider on out-of-network coverage requirements or reimbursements before seeking treatment.

3. Provide a superbill, if requested

A “superbill” is an itemized invoice of the services rendered to the client. It also includes relevant details like the clinician’s name, and the date and type of services, as well as your own identifying client data. This acts as a “proof of service.”

Superbills are often used as part of out-of-network coverage, and in cases where the insurance provider would like more information around the submitted claim. In the case of ketamine treatment, the client can request a superbill from the clinical provider —such as Mindbloom's affiliate medical practices— to share with their insurance provider at their request.

Does Mindbloom Accept Insurance for Ketamine Therapy?

It’s possible your insurance provider may fully or partially reimburse you for your Mindbloom program. After your first virtual visit, we can provide you with a superbill detailing treatment that you can submit for reimbursement. 

If you’d like to check with your insurer about the possibility of out-of-network reimbursement, here are the billing codes that Mindbloom uses:

• 99204 - 45 min initial consult
• 99214 - 25 min med mgmt. after Virtual Visit #1

Other Programs to Help Reduce Ketamine Treatment Costs

HSA/FSA Accounts

Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) are both tax-advantaged accounts that allow you to set money aside for qualified healthcare expenses designated by the Internal Revenue Service (IRS). Account owners are often issued a debit card that can be used to pay for services in person or online.

As some Mindbloom treatment services could be considered qualified expenses, it may be possible to utilize HSAs or FSAs to pay for treatment. To determine if these services are covered, try to pay with these cards during the checkout process. If you’re unable to make a payment with these methods, check with the card’s processor, as eligible expenses are ultimately determined by them. Mindbloom has no control over their determination.

Monthly payment plans and other financing options

Some ketamine treatment providers offer payment plans, or other arrangements that help to defer the up-front cost of treatment. This option can provide you with the immediate care you need while spreading the cost over a greater time period.

The Future of Insurance Coverage for Ketamine Therapy

Companies like Mindbloom are helping to remove barriers to access by making treatment more accessible and affordable. The more platforms, clinics, and providers are showing that ketamine therapy is a safe and effective mental health treatment, the more insurance companies are aware that this is a viable treatment method worth covering.

Additionally, groups of medical specialists, patients, and their lawyers are lobbying insurance companies to cover ketamine therapy treatments, both for mental health conditions and physical pain management.

Current lobbying efforts

Kimberly Juroviesky is the president of the Ketamine Taskforce, a non-profit organization which is working with regulators to change how ketamine is covered by insurance companies. The volunteer group is made up of patients, doctors, nurse practitioners, and patients’ lawyers.

She explains that in the long term, having ketamine treatment covered by insurance is beneficial for all sides.

“Insurance [companies] need to realize that [ketamine treatment] is less expensive than someone who’s suicidal who has to go to the hospital,” Juroviesky says. “When you’re covering a hospital bill that’s hundreds of thousands of dollars versus a few thousand dollars for six [in-person] ketamine treatments, it’s way less expensive than the hospital bill. Insurance companies have to see that this is saving them money in the long run."

While there’s no way of knowing when things will shift in the coverage of ketamine treatment, organizations like the Ketamine Taskforce and corporate entities are actively doing the work.

Medicare as a path to coverage

To date, Ketamine Taskforce has applied to Medicare to prove that ketamine is an effective option for both depression and chronic pain. The treatment method for pain is similar to depression. It’s administered through an IV but for a longer period of time —about four hours— and at a higher dosage.

The task force was told that they need two separate applications for each condition, so over the course of six months, they focused on the application for coverage of ketamine therapy for pain.

“Most practices are charging about $1200 to $1500 for pain infusion because they’re done over four hours,” explains Juroviesky. “That’s prohibitively expensive for most people.”

If Medicare approves the task force's application for coverage of ketamine treatment for pain, it will be on the National Coverage Determination, and insurance companies can no longer consider it experimental. If this step goes through, then the application for ketamine treatment for mental health is expected to pass as well.

“We’re hoping it will be easier to approve because Spravato has already been approved,” Juroviesky says. “It gives them proof that they’re already paying for this, and it came from ketamine, which is technically the same [compound].”

Additional steps are needed

The second hurdle for the Ketamine Taskforce is to get the American Medical Association (AMA) to create a Current Procedural Terminology (CPT) code, which can be used to get reimbursement for treatments. 

“Unfortunately right now there’s nothing on the books to be a code,” Juroviesky says. 

Before the code goes to committee, they send it to medical organizations, societies and associations they think will use the code.  She says that when they submitted an application to the AMA to get a code, they were declined by some of the organizations they assumed would support them.

“We haven’t figured it out, but that’s on pause,” she says. “Once we get approved by Medicare we will resubmit to the AMAs and show them that it was approved by Medicare.”

Change is coming

Although there isn’t currently an exact timeline for when ketamine therapy will be accepted as a treatment that’s covered by insurance plans, it’s only a matter of time until there is a shift. Efforts are underway and likely won’t stop until real change is achieved.