Mental Health Care With Medicare: What You Need to Know
For people seeking mental health care under Medicare, this year has brought welcome news. Beginning January 1, 2014, levels of reimbursement for psychological counseling, addiction services, and other forms of mental health care have been increased. With some exceptions, coverage now includes the cost of hospitalization for mental problems and overall reimbursement levels similar to those offered for medical services, for which Medicare generally pays 80 percent of the costs of therapy and medication, while patients and/or supplemental insurance pay 20 percent.
“Medicare regulations regarding mental health services are moving in the right direction,” says Anthony P. Weiner, MD, Director of Outpatient Geriatric Psychiatry at MGH. “It’s now possible to get more generous Medicare coverage for individuals who need treatment for all of the major diagnostic categories—mood disorders, anxiety disorders, psychotic disorders, and other major mental illnesses.
“However, challenges remain. Not the least of these is the current shortage of professionals who specialize in treating geriatric patients. The American Geriatrics Society has estimated that as of 2013, the U.S. was short 17,000 geriatricians, and that approximately 1,200 geriatricians would need to be trained annually over the next 20 years to meet projected demands for 2030.”
WHAT YOU CAN DO
Call 1-800-Medicare to learn more about Medicare mental health benefits. Other sources of information and/or help include:
- Medicare Savings Programs. These state programs help pay Medicare premiums and may also pay Part A and Part B deductibles and co-insurance. Call 1-800-Medicare and say “Medicaid” to get the telephone number for your state.
- Eldercare Locator. For individuals who cannot afford to pay for Medicare out-of-pocket expenses or medications, help may be available through government programs. Eldercare Locator (1-800-677-1116) can help provide referrals to local sources of assistance.
- State Health Insurance Assistance Programs (SHIP) offer free health insurance counseling in many states. Call 1-800-Medicare to find out how to contact your state’s SHIP program.
Because of this shortage, finding a practitioner who is trained in the care of older adults and who will accept the relatively low payment authorized by Medicare may be difficult for many Medicare recipients, Dr. Weiner says. The scarcity of mental health professionals nationwide who are willing and able to work with Medicare recipients is so severe that he advises patients and their families to learn about other options available to them in the event they are unable to access the care they need through Medicare.
Improved coverage
The changes in Medicare mental heath coverage were initiated by Congress in 2008 through passage of the Medicare Improvements for Patients and Providers Act, and since then increases in coverage have been gradually phased in until they took full force in 2014.
“Because the new regulations are very complicated, patients should make an effort to investigate Medicare mental health requirements as thoroughly as possible,” advises Jennifer De Souza, LICSW, a clinical social worker in the Department of Psychiatry at MGH who counsels older mental health patients on their options for financial help and/or treatment. “Individuals needing help or advice should contact a knowledgeable medical care provider, insurance administrator, or another expert before accessing care. Help can also be found at many local community or senior centers, or at city, county, or state elder services agencies.”
New Mental Health Benefits Under Medicare Initiated in 2014
A brief, but by no means inclusive, summary of the new Medicare mental health benefits follows:
▶ Outpatient services.
Under the new 2014 Medicare regulations, mental health patients pay an annual deductible of $147 for services and programs to help diagnose and treat mental health conditions on an outpatient basis. Medicare will help cover prescription drugs under Part D and pay 80 percent of the cost of mental health services. These services are covered under Medicare Part B (Medical Insurance) and may be provided by health professionals who accept Medicare payment. Medicare covers services provided by general practitioners, nurse practition-ers, physicians’ assistants, psychiatrists, and Medicare-certified clinical psychologists, clinical social workers, or clinical nurses.
Covered outpatient mental health services may include depression screening; psychiatric evaluation; individual and group therapy; family counseling to help with treatment; tests to ensure treatment efficacy; activity therapies, such as art or music therapy; occupational therapy; training and education related to care (such as how to inject a medication); substance abuse treatment; laboratory tests; and drugs that the patient cannot administer, such as injections provided by a physician.
▶ Inpatient services.
Medicare will help pay for inpatient mental health services in a psychiatric hospital or general hospital, but in contrast to coverage policies for hospitalization for medical care, there is a lifetime limit of 190 days for inpatient mental health care. Inpatient mental health care is covered under Medicare Part A with a $1,216 deductible and coinsurance for each benefit period. Part A covers room, meals, skilled nursing care, and other related services and supplies. Medicare pays 80 percent, and patients are responsible for 20 percent of the cost of the Medicare-approved amount for inpatient services provided by doctors and other providers.
▶ Alcoholism and drug abuse treatment.
Medicare will pay for both inpatient and outpatient treatment for alcoholism and drug abuse, provided a doctor certifies that the services are medically necessary, the services are rendered by a Medi-care-participating provider, and a doctor provides a plan of treatment. The cap on total inpatient treatment al-so applies here.
▶ Partial hospitalization for mental health treatment.
Medicare covers treatment for patients whose doctors certify that they need care in a hospital setting on a part-time basis, either only during the day, only at night, or only during weekends. Partial hospitalization pro-grams must be Medicare-certified and may be offered by hospital outpatient departments and local mental health centers. Partial hospitalization services covered by Medicare include individual or group therapy, oc-cupational therapy, prescription drugs not administered by the patient, activity therapies, family counseling intended to support treatment, training and education related to the patient’s plan of care, and services needed to diagnose the patient’s condition and evaluate care.
▶ Home care.
Regulations regarding coverage for home care for individuals who are housebound are still complicated. Seek expert advice to find out about benefits.
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