Mental Health and Medicare – Things to Know
Maintaining a healthy mental state is just as important as keeping up with your physical health. Unfortunately, many seniors suffer from some common mental health conditions, such as dementia and depression.
This is why it is vital that you learn how Medicare will help you in managing your mental health. Here are the things to know about Medicare and mental health services and treatments.
Medicare Part A covers your inpatient stays
Mental health patients could experience an inpatient stay in a few different types of facilities. Medicare Part A covers inpatient stays in places like a hospital, a skilled nursing facility, a mental healthcare clinic, and a psychiatric facility.
Depending on which type of facility you’re in will determine how Medicare Part A covers your stay. For instance, Medicare Part A covers your first 60 days in a hospital. However, not until you have met the Part A deductible for that benefit period which is $1364 in 2019.
A benefit period is how Medicare measure your Part A services. The period begins the day you are admitted in the hospital or facility and ends once you have spent 60 consecutive days out of the facility.
It is possible that you can experience multiple benefit periods in one year. If you do, you will have to pay the Part A deductible more than once a year.
Your copays past 60 days
If you require a longer than 60-day stay in the hospital, you will begin to incur a daily copay. As of 2019, for days 61 through 90, your daily copay is $341, while days 91 through 150 has a $682 daily copay. If your inpatient hospital stay exceeds 150 days, you are responsible for all Part A costs until you are released.
If your doctor recommends you finish your stay at a skilled nursing facility, Medicare will cover the first 20 days at 100%. After that, you have a daily copay of $170.50 for days 21 through 100. Part A also includes a lifetime benefit of 190 days in a mental healthcare clinic.
Medicare Part B covers your outpatient services
Outpatient services such as psychiatrist visits, diagnostic tests, and depression screenings are all covered under Part B. Medicare Part B will also cover mental health visits with a clinical psychologist, nurse specialist, and physician assistant, to name a few. However, the medical provider must accept Medicare assignment for Medicare to cover the visit.
After you have met your Medicare Part B annual deductible of $185 (in 2019), Medicare will share the cost with you. Part B will start to cover 80% of the Medicare-approved price for the service, while you cover the other 20%.
However, Medicare Part B covers your depression screening at 100% once per year as long as your doctor accepts Medicare assignment. These depression screenings are considered preventive care services.
Other preventive care services that Medicare Part B covers are annual wellness visits with your primary care physician. At these visits, your doctor will review your risk factor for depression among other things.
Medicare Part D covers your prescriptions
Medicare beneficiaries receive retail prescription drug coverage under Medicare Part D. Part D drug plans are sold by private insurance carriers, not Medicare. Therefore, each plan has different pre-set prices for copays, deductibles, and premiums.
Although the carriers can set their own prices, they must follow Medicare’s rules and restrictions for Part D. For instance, each Medicare Part D plan must include at least two drugs from each therapeutic class on their formulary.
A formulary is a list of medications that the Part D drug plan covers. Alongside each drug listed on the formulary is a “T” followed by a number. This represents which tier the drug plan classifies that particular drug under.
Depending on which tier the drug falls under, will determine your copay for that prescription. For example, if Citalopram has a “T1” next to it, you will pay the plan’s copay for tier one drugs.
Another rule Part D drug plan carriers must abide by is the deductible. In 2019, the highest a drug plan’s annual deductible can be is $415. Now, the deductible can be $0, but it cannot exceed $415.
Other stages and rules for Part D
There are four stages to a drug plan. The deductible is stage one, while the copays are stage two. Stage three is the infamous coverage gap or donut hole. During this stage, you will pay no more than 25% of the cost for brand-name drugs, while for generic drugs, you will pay 37%.
The last stage is catastrophic coverage. If you reach this stage, your plan will cover 95% of your drug costs until the end of the year.
Depending on what kind of mental health prescriptions you take, you may experience some utilization rules such as quantity limits (QL), prior authorization (PA), and step therapy (ST). Your formulary will list the abbreviations next to the drugs that have these rules.
It’s important to note that if you ever receive an injection or any drug that is administered to you while in a facility, Medicare Part D won’t cover it. Medications administered to you by a healthcare provider are subject to Medicare Part B coverage.
Medicare plans can help cover mental health services
As you can tell, you could experience several hundreds, even thousands of out-of-pocket expenses in one year managing your mental health. However, Medicare offers two types of plans that are meant to help cut your out-of-pocket spending.
These additional plans are Medigap plans and Medicare Advantage plans. These two types of plans work very differently, so it’s important that you research them equally to know which one is right for you.
Medigap plans cover your daily copays in the hospital
Remember those huge daily copays we mentioned earlier that you can accumulate if you stay in the hospital past 60 days? Fortunately, every Medigap plan available today covers those Part A copays at 100%.
Medigap plans also cover other gaps in Medicare such as deductible, coinsurance, and excess charges. In return for helping to cover your cost-sharing expenses, you will have to pay a higher premium than a Medicare Advantage plan premium. However, paying a higher monthly premium can help protect you from paying thousands of dollars within one benefit period.
Medicare Advantage plans usually have extra benefits
A great thing about Medicare Advantage plans is that the carriers usually add extra benefits to the plans that Original Medicare wouldn’t necessarily cover. Extra benefits such as inpatient mental health visits and outpatient therapy visits can sometimes be found in Medicare Advantage plans.
One thing that beneficiaries should keep in mind is that Medicare Advantage plans usually have networks. This means, if you see a psychiatrist, a primary care physician, and are admitted to a skilled nursing facility, you will need to make sure all of your doctors are in-network with your plan.
Medicare covers mental health services very similarly to how it would cover any other medically necessary service. Because you have the potential to experience a lot of out-of-pocket expenses, it’s smart to consider either a Medigap plan or Medicare Advantage plan.
No matter which route that you go, you can expect to have substantial help in managing your mental health.
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