Everything you need to know about Medicare Open Enrollment for 2027: How to Pick a Plan If You Need TMS — how it works, what it costs, and how to find a provider who actually knows what they're doing.
The TMS Patient Buyer's Guide
Everything to know before your first consult — questions to ask, what to expect, and how to compare providers.
Medicare covers TMS for treatment-resistant depression, and that is true whether you have Original Medicare or a Medicare Advantage plan. What changes between them is how you get approved, which clinics you can use and what you pay. Medicare’s open enrollment period runs October 15 to December 7, so this is the window to make sure the plan you choose for 2027 works with the TMS clinic you want, before you are mid-course and stuck with it.
This guide is general information, not insurance advice. Coverage rules vary by region and by plan, so confirm everything below with your own plan and clinic.
Key takeaways
- Open enrollment is October 15 to December 7. A plan has to receive your request by December 7 for coverage to start January 1 (Medicare.gov).
- TMS coverage under Original Medicare comes from regional Local Coverage Determinations (LCDs), which cover TMS for adults with treatment-resistant major depressive disorder.
- Medicare Advantage plans must follow those same coverage rules, but they can still require prior authorization and limit you to a network.
- If you want a Medigap policy, your window to buy one without health questions is narrow. Check it before you leave Original Medicare.
- Before you switch, ask the plan and the TMS clinic the same question: “Are you in network with this exact plan for TMS?”
How Medicare covers TMS
Original Medicare does not have one national TMS rule. Instead, each regional Medicare Administrative Contractor (MAC) publishes its own LCD. The ones we found are titled along the lines of “Transcranial Magnetic Stimulation (TMS)” or “rTMS in adults with treatment resistant major depressive disorder.” Noridian, for example, finalized an updated TMS LCD effective August 20, 2023 (Noridian). WPS and CGS publish their own versions.
The details differ by contractor, but LCDs of this type generally ask for the same kinds of things: a confirmed diagnosis of severe major depression, a documented lack of response to antidepressant medication in the current episode, treatment ordered by a psychiatrist with TMS experience, and a course delivered under a physician’s supervision. You can look up the LCD for your state in the Medicare Coverage Database, or ask your clinic which one applies to you.
One example: a Carelon form that summarizes the Medicare LCD (L37086) says the antidepressants tried must come from at least two different drug classes (Carelon form). We are not going to list every medication-trial count here, because details differ between contractors and change when an LCD is revised. Our longer guide, TMS and Medicare in 2026, and the Medicare insurance page go further, and your clinic’s intake team will know the current rule for your region.
Original Medicare vs. Medicare Advantage for TMS
Medicare.gov lays out the basic differences (compare Original Medicare and Medicare Advantage). Here is how they play out for someone planning TMS.
| Original Medicare (Part B) | Medicare Advantage (Part C) | |
|---|---|---|
| Choosing a clinic | Any provider that takes Medicare, anywhere in the U.S. | Usually in-network providers in the plan’s service area |
| Prior authorization | In most cases not required | May be required before certain services |
| What you pay | Part B deductible ($283 in 2026), then 20% of the Medicare-approved amount | Set by the plan: copays or coinsurance, with a yearly limit on covered services |
| Yearly out-of-pocket limit | None, unless you add supplemental coverage | Yes, set by the plan |
| Medigap | Can be bought to help with the 20% | Cannot be bought |
The 2026 Part B deductible and 20% coinsurance for outpatient mental health care come from Medicare.gov’s cost page. The same page notes that if you get a service in a hospital outpatient department, you may owe an additional amount to the hospital. That matters for TMS, because some programs run out of hospital clinics and some run out of private offices. Ask where your sessions would be billed. Medicare has not yet announced the 2027 Part B figures as of this writing; check Medicare.gov this fall.
What Original Medicare means in practice
You can walk into any TMS clinic that accepts Medicare. There is no network to check. You pay the Part B deductible and then 20% of the approved amount for each session, with no cap unless you have a Medigap policy or other secondary coverage. Under Original Medicare you generally do not need approval first, but your clinic still has to document that you meet your region’s LCD, so ask how they handle that paperwork.
What a Medicare Advantage plan means in practice
A Medicare Advantage plan has to cover what Original Medicare covers. CMS’s 2024 rule requires these plans to follow national and local coverage determinations, and it limits when a plan may add its own criteria: internal criteria are only allowed where Medicare’s coverage rules are not fully established (CMS fact sheet). In plain terms, a plan generally should not make TMS harder to get than the LCD does.
Plans can still use prior authorization to confirm you meet the medical criteria. Two protections from the same rule are worth knowing:
- A prior authorization approval for a course of treatment must be valid for as long as is medically reasonable and necessary, to avoid disruptions in care.
- If you are in the middle of treatment and switch to a new Medicare Advantage plan, the new plan must give you at least a 90-day transition period.
The biggest practical hurdle is the network. If the TMS clinic near you is out of network for the plan you pick, you may pay more or not be covered at all, depending on whether it is an HMO or PPO.
HMO, PPO and why it matters for TMS
Medicare’s guidance on provider networks (fact sheet) describes the main types:
- HMO: you generally must use the plan’s network, except for emergencies and a few other situations. Some HMOs have a point-of-service option that lets you go out of network for certain services at a higher cost.
- PPO: you can see providers outside the network, but you usually pay more.
TMS means about five visits a week for roughly six to nine weeks. A higher out-of-network share, repeated that many times, adds up fast. If a particular clinic or psychiatrist is the reason you want TMS, build your plan choice around that.
How to check a plan’s network for a TMS clinic
Directories can be out of date, so check in more than one place.
- Start with the plan’s provider directory. Find it on the plan’s website, or call and ask for one. Search for the clinic and for the psychiatrist who will order the treatment.
- Call the TMS clinic. Ask: “Do you contract with [exact plan name] for TMS? Is that for CPT codes 90867, 90868 and 90869?” Those are the codes TMS is billed under, as state Medicaid notices such as New York’s list them. Give them the plan name exactly as it appears on your card, since one insurer can sell many different plans.
- Call the plan. Ask whether TMS requires prior authorization, and what you would owe per session in network and out of network.
- Ask who handles authorization. Most clinics submit it for you, but confirm.
- Re-check each year. Medicare says plans can add or remove providers at any time during the year, and that providers can leave a network, with the plan making a good-faith effort to give at least 30 days’ notice. Medicare recommends checking whether your providers are in the plans you’re considering during open enrollment each year.
Medicare’s plan finder, at Medicare.gov/plan-compare, lets you compare plans in your area. You can also call 1-800-MEDICARE, or get free one-on-one help from your state’s SHIP counselors (call 877-839-2675 and say “Medicare” to find yours; see shiphelp.org).
Where Medigap fits in
Medigap (Medicare Supplement Insurance) is sold by private insurers and works only with Original Medicare. It exists to help pay costs Medicare leaves to you, such as the 20% coinsurance. Which costs a given plan pays depends on its letter, so check Medicare’s plan benefit chart and ask how any copays apply to outpatient mental health visits.
The timing is the catch. Your Medigap open enrollment period is a one-time, six-month window that starts the first month you are 65 or older and enrolled in Part B. After that, Medicare says options may be limited and the policy may cost more, because there is no federal guarantee an insurer will sell you one (Medicare.gov). Some states add protections, so check with your State Insurance Department. If you are thinking of leaving Original Medicare for Advantage, remember that switching back later may mean you cannot get a Medigap policy at the same price, or at all.
If you are already in a Medicare Advantage plan
Open enrollment is not your only chance. Between January 1 and March 31, people already in a Medicare Advantage plan can switch to another Advantage plan or go back to Original Medicare (Medicare.gov). That helps if you find out in January that your clinic is out of network. It does not let you move from Original Medicare into Advantage during those months.
Do not switch plans in the middle of a TMS course without calling the clinic first. The 90-day transition rule helps, but a clean start date is easier on you.
A simple checklist before December 7
- Write down the clinic and psychiatrist you want to use for TMS.
- Look up your region’s LCD, or ask the clinic which MAC applies.
- Check each plan you are considering for network status, prior authorization and per-session cost.
- If you are staying in Original Medicare, decide whether you need Medigap and whether you can still buy it.
- Get names, dates and call reference numbers when you call. You will want them if there is a dispute.
- If you do not have a clinic yet, find a TMS clinic near you and ask which plans they accept, then take the candidate quiz if you are still deciding whether TMS is right for you.
If your coverage is denied, our guide to TMS insurance appeals walks through what to do next. For older adults specifically, see TMS for older adults.
Frequently asked questions
Does Medicare cover TMS for depression?
Yes. Original Medicare covers TMS for adults with treatment-resistant major depressive disorder under regional LCDs, and Medicare Advantage plans must follow those coverage rules. You still pay your share of the cost, and the exact criteria depend on your region.
Can I change my Medicare plan if my TMS clinic isn’t in network?
During open enrollment (October 15 to December 7) you can switch plans for coverage starting January 1. If you are already in a Medicare Advantage plan, you also have January 1 to March 31 to switch to another Advantage plan or return to Original Medicare. Outside those windows you generally need a qualifying special circumstance.
Do I need prior authorization for TMS on Medicare?
Under Original Medicare you generally do not need approval first, though your clinic must document that you meet the LCD. Medicare Advantage plans may require prior authorization, so ask the plan before you book your mapping session.
Will a Medigap policy pay for my TMS?
Medigap is designed to help with costs Original Medicare leaves, like the 20% coinsurance, but what each plan pays depends on the plan. It cannot be used with a Medicare Advantage plan. Ask the insurer how it handles outpatient mental health services.
What if I’m halfway through TMS when my plan changes on January 1?
Talk to your clinic now, before December 7. If you switch to a new Medicare Advantage plan mid-treatment, CMS requires at least a 90-day transition period. Even so, confirm that the new plan recognizes your authorization and that your clinic is in network.
Where can I get free help comparing plans?
Your State Health Insurance Assistance Program (SHIP) offers free, unbiased Medicare counseling. Call 877-839-2675 to find your local program, or call 1-800-MEDICARE.
