Does Medi-Cal Cover TMS in California?

Does Medi-Cal cover TMS in California?

Yes. As of August 1, 2024, Medi-Cal covers TMS for major depressive disorder, for adults and adolescents aged 15 and older, with prior authorization. This was a real change. Before then, TMS was only reachable through county specialty mental health programs. Now it is a standard Medi-Cal benefit.

Here is who qualifies, how the coverage works, and how to start if you have Medi-Cal.

What changed in 2024

In July 2024, California’s Department of Health Care Services (DHCS) added TMS as a covered Medi-Cal benefit, effective August 1, 2024. Before that, TMS was only reimbursed under the county Specialty Mental Health Services benefit, which put it out of reach for many members. The update opened TMS across Medi-Cal for depression that has not responded to medication.

Who qualifies

• Diagnosis: major depressive disorder (MDD).
• Age: adults and adolescents 15 and older.
• Prior treatment: documented inadequate response to antidepressant medications, usually more than one and from different classes.

As with commercial plans, TMS is used when medication has not worked well enough, not as a first step.

How Medi-Cal covers TMS

Medi-Cal covers TMS through your Medi-Cal managed care plan, or, for members with a severe level of impairment, through the county Mental Health Plan. Either way:

• Prior authorization is required. Your provider submits it through the plan’s behavioral health team.
• The full course is covered when criteria are met, including the mapping session, the daily treatment sessions, and maintenance sessions.
• Your out-of-pocket cost is usually minimal, because Medi-Cal has little or no cost-sharing for covered services.

How many sessions Medi-Cal covers

A standard course for depression is about 30 sessions, five days a week for roughly six weeks. The Medi-Cal benefit includes the initial mapping session, the daily treatment sessions, and maintenance sessions after the course when they are medically necessary. Your exact number is set by your diagnosis and your provider’s treatment plan.

How to start TMS with Medi-Cal

1. Find a provider who offers TMS and accepts Medi-Cal. They confirm whether TMS fits your diagnosis and history.
2. Prior authorization. Your provider documents your diagnosis and past antidepressant trials and submits the request to your plan.
3. Begin treatment once it is approved, usually a daily schedule over about six weeks.

Does Exxceed Wellness accept Medi-Cal?

Yes. We accept Medi-Cal for TMS. If you have Medi-Cal and depression that has not improved on medication, we can confirm whether you qualify, handle the prior authorization with your plan, and deliver treatment at our Hayward clinic. Contact us to check your Medi-Cal coverage, or learn more about our TMS program.

Frequently asked questions

Does Medi-Cal cover TMS for depression?

Yes, for major depressive disorder in members aged 15 and older, with prior authorization, as of August 1, 2024.

Does Medi-Cal cover TMS for OCD?

The Medi-Cal TMS benefit is for major depressive disorder. Coverage for OCD or other uses is not part of that benefit and would depend on your plan, so ask before you start.

Do I need a referral?

You need prior authorization, which your TMS provider submits. Some managed care plans or county programs may also involve a referral. We handle the authorization for you.

How much does TMS cost with Medi-Cal?

Medi-Cal has little or no cost-sharing for covered services, so most members pay very little out of pocket once TMS is authorized. For the full picture, see our TMS cost guide.

What if I have another plan too?

Coverage rules differ by plan. See our guides on whether Kaiser covers TMS, with Blue Shield and Medicare guides on the way.

References

1. National Health Law Program. Fact Sheet: Medi-Cal Coverage of Transcranial Magnetic Stimulation (TMS), 2024: healthlaw.org.
2. California Department of Health Care Services (DHCS): Medi-Cal added TMS as a covered benefit effective August 1, 2024.
3. Perera T, et al. The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimulation. 2016;9(3):336-346: PubMed.

Educational information only, not medical or financial advice. Medi-Cal coverage and criteria for TMS vary by managed care plan and county, and can change. TMS is FDA-cleared for major depressive disorder, including as an add-on for adolescents 15 and older. Confirm your eligibility and benefits with a qualified clinician and your Medi-Cal plan.