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As artificial intelligence becomes increasingly integrated into elderly healthcare systems, smart elderly health care (SEHC) has been promoted as a promising policy enhancing mental health and well-being among the elderly in China. This study examines the impact of SEHC on mental health and inequality among the elderly, with a particular focus on its unequal selection effect and the expansion of individual adaptability. Drawing on longitudinal data from China Health and Retirement Longitudinal Study, we adopt staggered difference-in-difference method to estimate the effects of SEHC policy implementation on elderly mental health and inequality, conduct robustness checks, heterogeneity tests, and mechanism analyses. SEHC significantly improves the mental health of the elderly (β = -1.391, P < 0.01) while simultaneously intensifying mental health inequality (β = 0.278, P < 0.01). However, these gains are disproportionately concentrated among individuals with higher income, lower hospitalization cost, higher educational attainment, and urban residency. Mechanism analysis reveals that SEHC improves mental health primarily by enhancing social participation and reducing hospitalization cost, with these adaptive benefits concentrated among higher-income individuals. While SEHC demonstrates significant potential to enhancing mental well-being among the elderly, it also generates disparities in mental health outcomes across different socioeconomic groups. To address this inequality, policymakers should implement inclusive intervention strategies that guarantee equitable and sustainable access to artificial intelligence-driven mental health benefits in elderly healthcare.