Everything you need to know about Does Medi-Cal Cover TMS? Eligibility, Prior Authorization and Where to Go — how it works, what it costs, and how to find a provider who actually knows what they're doing.
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Yes, Medi-Cal covers TMS. Since August 1, 2024, it has been a standard Medi-Cal benefit for members age 15 and older, and a treatment authorization request (TAR), also called prior authorization, is required before coverage is approved. For years the answer was murkier, so a lot of older web pages still say Medi-Cal doesn’t cover it. Here is what has changed, what plans actually ask for, and where to start.
This is general information, not legal or medical advice. Medi-Cal rules and plan forms get updated, so confirm details with your own plan.
Key takeaways
- TMS became a standard Medi-Cal benefit effective August 1, 2024. A TAR is always required, and members must be at least 15.
- You can reach TMS through your Medi-Cal managed care plan or through your county mental health plan. Under DHCS’s “No Wrong Door” policy, either one is a valid starting point.
- The exact medical criteria are set by each plan, not in one statewide rulebook. The forms we reviewed ask about depression severity, medication trials and exclusions like psychosis or implanted metal.
- If you are denied, you can appeal. Deadlines are short, so read your denial notice the day it arrives.
What changed in 2024
Before August 2024, TMS sat on the Medi-Cal “TAR and Non-Benefit List.” That label confused plans, and the National Health Law Program (NHeLP) documented managed care plans denying TMS on the grounds that it was a non-benefit. DHCS then removed that status. In NHeLP’s October 2024 summary, TMS is “now a standard Medi-Cal benefit; however, a TAR is always required before coverage is approved and only beneficiaries over 15 are eligible for the benefit” (NHeLP fact sheet). DHCS posted the change on its Medi-Cal provider site as a policy update for CPT codes 90867, 90868 and 90869.
Those three codes are how TMS is billed: 90867 for the initial session (including mapping and motor threshold), 90868 for treatment sessions and 90869 for sessions that include re-determining the motor threshold. You may hear your clinic mention them when they submit your TAR. For more on how they work, see our explainer on TMS CPT codes.
Who counts as eligible
Eligibility has two layers: being on Medi-Cal, and meeting the TMS criteria your plan uses.
Age. Anthem Blue Cross’s Medi-Cal provider notice and CenCal Health’s authorization form both list 15 as the minimum age (Anthem, CenCal Health). NHeLP notes that the FDA has cleared TMS devices for adolescents, which is likely why the line sits at 15. For younger teens and kids under 21 in general, Medi-Cal follows federal EPSDT rules, which require coverage of medically necessary services; see Medicaid.gov on EPSDT. Our post on TMS for adolescents covers the clinical side.
Diagnosis. The plan forms we reviewed center on major depressive disorder. A Carelon Medi-Cal request form, used for county plans, asks whether the member has “a confirmed diagnosis of moderate or severe major depressive disorder (MDD) and no psychotic symptoms” (Carelon form). CenCal’s form lists several depression codes, plus dysthymia and OCD, as TMS diagnoses it will consider.
Treatment history. Plans generally want to see that other treatments have not been enough. CenCal’s form, for example, lists “at least two adequate antidepressant trials, or intolerance to at least two classes” as an approval criterion, and the Carelon form asks about psychotherapy and about whether the member has declined ECT. Your plan’s exact wording may differ, which is why your psychiatrist’s documentation matters. Our post on failed antidepressant trials explains what usually counts.
Exclusions. CenCal’s form lists several reasons a member isn’t eligible: psychotic symptoms or disorders such as schizophrenia, metallic or magnetic-sensitive implants within 30 cm of the coil, and cochlear implants or deep brain stimulation devices. See who should not get TMS for the clinical reasons.
Prior authorization: what gets submitted
A TAR is how a plan decides whether TMS is medically necessary for you. Your clinic usually files it. Based on the plan forms we reviewed, expect it to include:
- Your diagnosis and a baseline depression score from a standard scale such as the PHQ-9. CenCal’s form, for instance, sets a minimum baseline score for each scale.
- A record of medications and therapy you have tried, with doses and dates.
- Your clinician’s treatment plan, including the number of sessions.
- Confirmation that you have no exclusions.
On session counts, CenCal’s form says it will approve “up to 8 weeks for the completion of the initial evaluation” using 90867 and “up to 35 sessions of initial TMS therapy” using 90868 and 90869. That is one plan’s limit, not a statewide rule, so ask yours. For how this fits with the typical number of sessions, see TMS week by week.
Prior authorization is not a promise of payment. Healthcare.gov’s glossary puts it plainly: “Preauthorization isn’t a promise your health insurance or plan will cover the cost” (HealthCare.gov). Ask your plan to confirm in writing what was approved and for how long.
Two doors: managed care plan or county mental health plan
Medi-Cal splits mental health coverage between your managed care plan and your county mental health plan. NHeLP explains that TMS had been available through the county’s specialty mental health services before DHCS opened it up through managed care. Anthem’s notice confirms that members can still use the county route under the “No Wrong Door” policy.
In practice:
- Start with the number on your Medi-Cal plan card. Ask for the behavioral health line and say, “I want to ask about TMS for depression. What do you need from my provider?”
- If your plan says it isn’t the right place, ask for a handoff. Ask them to refer you to your county mental health plan, and ask for the name of the person you were referred to.
- Ask for in-network clinics. Not every TMS clinic accepts Medi-Cal, and fewer accept every Medi-Cal plan. Ask the clinic which plans it contracts with.
- Tell your psychiatrist or prescriber. A TAR needs a clinician to submit it and support it with records.
Some plans use a behavioral health vendor to review requests. The Carelon form, for example, notes that Medi-Cal requests are “reviewed using InterQual criteria,” and that for a repeat course, InterQual expects prior TMS to have taken place at least six months earlier. If you are interested in a second course, our guide to TMS retreatment goes into this.
Where to find a clinic
Our directory lists TMS clinics across California. Browse clinics by state and use the insurance filters, but confirm Medi-Cal participation directly with the clinic and your plan, since our listings can’t tell you which Medi-Cal plan a specific clinic is in network with today. For more on how we handle insurance information, see Medi-Cal on our insurance pages and the Medicaid overview. If you aren’t sure TMS is the right next step, the candidate quiz is a low-pressure way to start the conversation with your doctor.
If you are denied
Denials are common enough that you should know the path before you need it.
- Read the notice. It states why the request was denied and how long you have to appeal.
- File a plan appeal first. For Medi-Cal managed care, DHCS explains that you appeal to the plan before asking for a State Hearing. See the DHCS grievance and appeal chart.
- Ask about Independent Medical Review. The California Department of Managed Health Care runs IMR for denials based on medical necessity, and if it overturns a denial the plan must authorize the service (DMHC). Check which route applies to your plan, because sources note you may not be able to use IMR and a State Hearing for the same denial.
- Get a letter from your psychiatrist. A short letter that spells out your history carries real weight.
- Ask about free help. DHCS has an Ombudsman for managed care members, and local legal aid offices can help with appeals.
Our TMS insurance appeals guide covers appeal writing in more detail.
Frequently asked questions
Does Medi-Cal cover TMS for depression?
Yes. TMS has been a standard Medi-Cal benefit since August 1, 2024 for members 15 and older. A treatment authorization request is required, and your plan decides whether you meet its medical criteria.
Do I need prior authorization for TMS on Medi-Cal?
Yes. Every source we reviewed, including NHeLP’s summary and the plan notices, says a TAR is required before coverage is approved. Your clinic normally submits it.
Can I get TMS through my county mental health plan instead of my managed care plan?
Yes. Anthem’s provider notice says members can still pursue TMS through the county specialty mental health benefit under DHCS’s No Wrong Door policy. If one door is closed, ask for a referral to the other.
Does Medi-Cal cover TMS for OCD or anxiety?
We could not verify statewide coverage for conditions other than major depressive disorder. One plan form we reviewed (CenCal) lists OCD among its listed diagnoses, but Carelon’s form asks about MDD first and gives only a general line for any other primary condition. Ask your plan directly.
How many TMS sessions will Medi-Cal approve?
It depends on the plan. CenCal’s form allows an initial evaluation plus up to 35 treatment sessions. Other plans may differ, so ask yours how many sessions it authorizes and what happens if your clinician requests more.
What if my clinic doesn’t take Medi-Cal?
Ask the clinic for a referral to one that does, and ask your Medi-Cal plan for in-network TMS providers. You can also search our directory and call to confirm.
