Medicare and Your Mental Health Benefits 2012.pdf

7/29/2019 Medicare and Your Mental Health Benefits 2012.pdf

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This ocial government booklet has inormation about mental

health benefts or people with Original Medicare, including:

Who is eligible

Outpatient & inpatient benefts

Prescription drug coverage

Help or people with limited income & resources

Where to get the help you need


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Te inormation in this booklet was correct when it was printed.Changes may occur aer printing. Visit www.medicare.gov, orcall 1-800-MEDICARE (1-800-633-4227) to get the most currentinormation. Y users should call 1-877-486-2048.

Medicare & Your Mental Health Benets isnt a legal document.

Ocial Medicare Program legal guidance is contained in the relevantstatutes, regulations, and rulings.
http://www.medicare.gov/http://www.medicare.gov/


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Table o Contents

IntroductionMental health care & Medicare

Medicare helps cover mental health services

Section 1: Outpatient mental health care &

proessional servicesWhat Original Medicare covers

What you payMedicare may cover partial hospitalization

What Original Medicare doesnt cover

Section 2: Inpatient mental health careWhat Original Medicare covers

What you pay

What Original Medicare doesnt cover

Section 3: Medicare prescription drug coverage (Part D)Medicare drug plans have special rulesLearn more about Medicare prescription drug coverage

Section 4: Get the help you needHelp if you have limited income & resources

Your rights as a person with Medicare

Your Medicare appeal rights

Mental health resources

Section 5: Defnitions
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I you or someone you know is in crisis and would like to speak

with a crisis counselor, call the ree and condential National Suicide

Prevention Lieline at 1-800-273-ALK (1-800-273-8255). Y usersshould call 1-800-799-4Y (1-800-799-4889). You can call and speakwith a counselor 24 hours a day, 7 days a week. Call the Lieline:

o speak to someone who cares

I you eel you might be in danger o hurting yoursel

I youre concerned about a amily member or riend

o nd reerrals to mental health treatments and services in yourarea

I youre in immediate medical crisis, call 911.


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Introduction

Mental health care & MedicareMental health conditions like depression or anxiety can come at anyage and can happen to anyone. I you think you may have problems thatafect your mental health, you can get help. alk to your doctor or otherhealth care provider i you have:

Toughts o ending your lie (like a xation on death or suicidalthoughts or attempts)

Sad, empty, or hopeless eelings

Loss o sel worth (like worries about being a burden, eelings oworthlessness, or sel-loathing)

Social withdrawal and isolation (reluctance to be with riends, engagein activities, or leave home)

Little interest in things you used to enjoy

A lack o energy

rouble concentrating

rouble sleeping (like diculty alling asleep or staying asleep,oversleeping, or daytime sleepiness)

Weight loss or loss o appetite

Increased use o alcohol or other drugs

Mental health care includes services and programs to help diagnoseand treat mental health conditions. Tese services and programs maybe provided in outpatient and inpatient settings. Medicare helps coveroutpatient and inpatient mental health care, as well as prescription drugsyou may need to treat a mental health condition. Tis booklet gives youinormation about mental health benets in Original Medicare.

Highlighted words are dened here.

I you get your Medicare benefts through a Medicare Advantage Plan

(like an HMO or PPO) or other Medicare health plan, check your plansmembership materials and call the plan or details about how to get yourMedicare-covered mental health benets.
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Medicare helps cover mental health servicesMedicare Part A (hospital insurance) helps cover mental health care

i youre a hospital inpatient. Part A covers your room, meals, nursingcare, and other related services and supplies.

Medicare Part B (medical insurance) helps cover mental health servicesthat you would generally get outside o a hospital, including visits with apsychiatrist or other doctor, visits with a clinical psychologist or clinicalsocial worker, and lab tests ordered by your doctor. Part B may also payor partial hospitalization services, i you need intensive coordinatedoutpatient care. See more inormation about partial hospitalizationservices.

Medicare prescription drug coverage (Part D) helps cover drugs youmay need to treat a mental health condition.
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Section 1: Outpatient mental health

care & proessional services

What Original Medicare coversMedicare Part B helps cover mental health services and visits with the

ollowing types o health proessionals (deductibles and coinsurance mayapply):

A psychiatrist or other doctor

Clinical psychologist

Clinical social worker

Clinical nurse specialist

Nurse practitioner

Physician assistant

Te health proessionals listed above (except psychiatrists and otherdoctors) must accept assignment i they participate in the Medicareprogram. Ask your health care provider i they accept assignment beoreyou schedule an appointment.


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Medicare Part B covers outpatient mental health services, including servicesthat are usually provided outside a hospital (like in a clinic or doctors ortherapists oce), and those provided in a hospitals outpatient department.Part B helps pay or the ollowing covered services (deductibles andcoinsurance may apply):

Individual and group psychotherapy with doctors or certain other licensedproessionals allowed by the state to give these services.

Family counseling i the main purpose is to help with your treatment.

esting to nd out i youre getting the services you need and i yourcurrent treatment is helping you.

Psychiatric evaluation.

Medication management.

Occupational therapy thats part o your mental health treatment.

Certain prescription drugs that arent usually sel administered (drugsyou would normally take on your own), like some injections.

Individual patient training and education about your condition.

Diagnostic tests.

Partial hospitalization may be covered. See more ino.

A one-time Welcome to Medicare preventive visit. Tis visit includes areview o your potential risk actors or depression. (Note: Tis visit is onlycovered i you get it within the rst 12 months you have Part B.) You paynothing or this visit i your doctor or other health care provider acceptsassignment.

A yearly Wellness visit. Medicare covers a yearly Wellness visit onceevery 12 months (i youve had Part B or longer than 12 months). Tisis a good time to talk to your doctor or other health care provider aboutchanges in your mental health so he or she can evaluate your changes yearto year. You pay nothing or your yearly Wellness visit i your doctor orother health care provider accepts assignment.

A yearly depression screening. Medicare covers one depression screening

per year. Te screening must be done in a primary care doctors oce orprimary care clinic that can provide ollow-up treatment and reerrals.You pay nothing or your yearly depression screening i your doctor orhealth care provider accepts assignment.


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What you payAer you pay your yearlyMedicare Part Bdeductible, how much you

pay or mental health services will depend on whether the purpose oyour visit is to diagnose your condition or to get treatment.

For visits to a doctor or other health care provider to diagnose yourcondition, you pay 20% o the Medicare-approved amount.

For outpatient treatment o your condition (like psychotherapy), youpay 40% o the Medicare-approved amount in 2012. Congress passedlegislation that reduces how much people with Medicare pay oroutpatient mental health treatment to be consistent with coinsuranceamounts or other medical services. How much you pay or theseservices will decrease to 35% in 2013 and 20% in 2014.

Note: I you get your services in a hospital outpatient clinic or hospitaloutpatient department, you may have to pay an additionalcopaymentor coinsurance amount to the hospital. Tis amount will varydepending on the service provided but will be between 20%40% o theMedicare-approved amount.

Note: I you have a Medicare Supplement Insurance (Medigap) policyor other health insurance coverage, tell your doctor or other health careprovider so your bills get paid correctly.
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Section 2: Inpatient mental health

care

What Original Medicare coversMedicare Part A helps pay or mental health services you get in a

hospital that require you to be admitted as an inpatient. You can getthese services either in a general hospital or in a psychiatric hospitalthat only cares or people with mental health conditions. Regardless owhich type o hospital you choose, Part A will help cover mental healthservices.

I youre in a psychiatric hospital (instead o a general hospital), Part Aonly pays or up to 190 days o inpatient psychiatric hospital servicesduring your lietime.

What you payMedicare measures your use o hospital services (including services youget in a psychiatric hospital) and skilled nursing acility (SNF) servicesin benet periods. A benet period begins the day youre admitted asan inpatient in a hospital (either general or psychiatric) or a SNF. Tebenet period ends aer you havent had any inpatient hospital care orskilled care in a SNF or 60 days in a row. I you go into a hospital orSNF again aer 60 days, a new benet period begins, and you must pay anewdeductibleor any inpatient hospital services you get.

Teres no limit to the number o benet periods you can have when youget mental health care in a general hospital. You can also have multiplebenet periods when you get care in a psychiatric hospital, but theres alietime limit o 190 days.


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For each benet period as a hospital inpatient, you pay the ollowing in 2012:

$1,156 deductible per benet period

$0 or the rst 60 days o each benet period $289 per day or days 6190 o each benet period

$578 per lietime reserve day aer day 90 o each benet period (up to amaximum o 60 days over your lietime)

Note:Medicare Part B also helps cover mental health services provided bydoctors and other health care proessionals i youre admitted as a hospitalinpatient. You pay 20% o the Medicare-approved amount or these mentalhealth services while youre a hospital inpatient.

Note: I you have a Medicare Supplement Insurance (Medigap) policyor other health insurance coverage, tell your doctor or other health careprovider so your bills get paid correctly.

What Original Medicare doesnt coverMedicare doesnt cover:

Private duty nursing

A phone or television in your room

Personal items (like toothpaste, socks, or razors)

A private room (unless medically necessary).
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Section 3: Medicare prescription

drug coverage (Part D)o get Medicare prescription drug coverage, you must join a MedicarePrescription Drug Plan. Medicare drug plans are run by insurancecompanies and other private companies approved by Medicare. Each

Medicare drug plan can vary in cost and in the specic drugs it covers.Its important to know your plans coverage rules and your rights.

Medicare drug plans have special rules

Will my plan cover the drugs I need?

Most Medicare drug plans have a list o drugs that the plan covers,called a ormulary. Medicare drug plans arent required to cover alldrugs, but theyre required to cover all or almost all anti-depressant,

anticonvulsant, and antipsychotic medications, which may be necessaryto keep you mentally healthy. Medicare reviews each plans ormularyto make sure it contains a wide range o drugs and that it doesntdiscriminate against certain groups (like people with disabilities ormental health conditions).

I you take prescription drugs or a mental health condition, its

important that you know whether a plan covers the drug beore you

enroll.

Tere are certain drugs that Medicare drug plans arent required tocover, like drugs or weight loss or gain. Some Medicare drug plans maychoose to pay or these drugs as an added benet. Also, some statesmay cover these drugs i you have Medicaid. See more inormation onMedicaid. Be sure to ask your prescriber (your doctor or other healthcare provider who is legally allowed to write prescriptions) and your planany questions you have about the drugs you need.


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Can my drug plans ormulary change?

A Medicare drug plan can make some changes to its ormulary during the

year according to guidelines set by Medicare. I youre currently taking adrug and the plans ormulary changes, in most cases, youll be notiedbeore the change is made, and the plan will usually cover the drug oryou or the rest o the plan year. Te cost o a drug can also change duringthe year, but your copayments or coinsurance should stay the same.

What i my prescriber thinks I need a certain drug that my plan doesnt cover?

I you belong to a Medicare drug plan, you have the right to request acoverage determination (including an exception).

Request a coverage determination

You, your doctor, or other prescriber can request that your plan covera drug you need. You can request a coverage determination i yourpharmacist or plan tells you:

A drug you believe should be covered isnt covered

A drug is covered at a higher cost than you think you should have topay

You have to meet a plan coverage rule (like prior authorization) beore

you can get the drug you requested It wont cover a drug on the ormulary because the plan believes you

dont need the drug


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Request an exception

You, your doctor, or other prescriber can request an exception (a type o

coverage determination) i: You think your plan should cover a drug thats not on its ormulary

because the other treatment options on your plans ormulary wontwork or you

Your doctor or other prescriber believes you cant meet one o yourplans coverage rules (like prior authorization, step therapy, orquantity or dosage limits)

You think your plan should charge a lower amount or a drug youretaking on the plans non-preerred drug tier because the othertreatment options in your plans preerred drug tier wont work oryou

I you request an exception, your doctor or prescriber will need to givea supporting statement to your plan explaining why you need the drugyoure requesting. Check with your plan to nd out i it will requireyour prescriber to submit a supporting statement in writing.

What i I disagree with my plans coverage determination or exception

decision?

Once your plan has gotten your request, in most cases, it has 72 hours(or 24 hours i you request that a ast decision be made) to notiy youo its decision. I you disagree with your Medicare drug plans coveragedetermination or exception decision, you have the right to appeal thedecision. Te plans written decision will explain how to le an appeal.Read this decision careully.

For more inormation on how to le an appeal and your appeal rights:

Visit www.medicare.gov/publications to view or print the bookletMedicare Appeals.

Visit www.medicare.gov/appeals.

Call 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.
http://www.medicare.gov/publicationshttp://www.nami.org/http://www.nami.org/http://www.medicare.gov/publications


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Learn more about Medicare prescription drug coverageo nd out more about Medicare prescription drug coverage, visit www.

medicare.gov/publications to view or print Your Guide to MedicaresPrescription Drug Coverage. You can also learn more and getpersonalized help comparing plans by:

Visiting www.medicare.gov/nd-a-plan.

Calling 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

Calling your State Health Insurance Assistance Program (SHIP).o get their phone number, visit www.medicare/contacts, or call1-800-MEDICARE.

Have your Medicare card, a list o your drugs and their dosages, and thename o the pharmacy you use available.
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Section 4: Get the help you needMedicare is here to help you get the inormation you need.

Tis section includes inormation about the ollowing:

Help i you have limited income & resources

Your rights as a person with Medicare

Your Medicare appeal rights


Help i you have limited income & resources

Extra Help paying your Medicare prescription drug costs

Extra Help is a Medicare program to help people with limited incomeand resources pay Medicare prescription drug costs. You may qualiyor Extra Help i your yearly income and resources are below certain

amounts. I you dont automatically qualiy or Extra Help, you can stillapply.

For more inormation:

Visit www.socialsecurity.gov. o apply or Extra Help online, visitwww.socialsecurity.gov/i1020.

Call Social Security at 1-800-772-1213. Y users should call1-800-325-0778. You can apply or Extra Help by phone or get a paperapplication.

Visit or call your State Medical Assistance (Medicaid) oce.Visit www.medicare.gov/contacts, or call 1-800-MEDICARE(1-800-633-4227) to get the phone number. Y users should call1-877-486-2048.
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State Pharmacy Assistance Programs (SPAPS)

Many states have SPAPs that help certain people pay or prescription drugs

based on nancial need, age, or medical condition. Each SPAP makes itsown rules on how to provide assistance to its members. o nd out i theresan SPAP in your state and how it works, call your State Health InsuranceAssistance Program (SHIP). Visit www.medicare.gov/contacts, or call1-800-MEDICARE (1-800-633-4227) to get the phone number. Y usersshould call 1-877-486-2048.

Medicare Savings Programs

I you have limited income and resources, you may be able to get help rom

your state to pay your Medicare costs (like deductibles and coinsurance) iyou meet certain conditions.


Call or visit your State Medical Assistance (Medicaid) oce, and ask orinormation on Medicare Savings Programs. Call i you think you qualiy,even i you arent sure. o get the phone number or your state, visit www.medicare.gov/contacts, or call 1-800-MEDICARE.

Visit www.medicare.gov/publications to view the brochure GetHelp With Your Medicare Costs: Getting Started. You can also call

1-800-MEDICARE to nd out i a copy can be mailed to you. Contact your State Health Insurance Assistance Program (SHIP). Visit

www.medicare.gov/contacts, or call 1-800-MEDICARE to get the phonenumber.

Medicaid

Medicaid (also called Medical Assistance) is health coverage available tocertain people and amilies who have limited income and resources. Terules or counting your income and resources depend on which state you

live in. Eligibility may also depend on other actors, like how old you areand whether youre blind or have other disabilities. Even i you arent surewhether you qualiy, i your income is limited, and i you or someone inyour amily needs health care, you should apply or Medicaid and have aqualied caseworker in your state look at your situation.
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o see i you qualiy, call your State Medical Assistance (Medicaid)

oce. Visit www.medicare.gov/contacts, or call 1-800-MEDICARE(1-800-633-4227) to get the phone number. Y users should call1-877-486-2048.

o learn about the Medicaid program, visit www.medicare.gov/publications to view or print the brochure Medicaid: GettingStarted.

Your rights as a person with MedicareAll people with Medicare have certain rights and protections designed

to protect you when you get health care, make sure you get the healthcare services that the law says you can get, protect you against unethicalpractices, and protect your privacy. o learn more about your rightsas a person with Medicare, visit www.medicare.gov/publications to

view the booklet Medicare Rights and Protections. You can call1-800-MEDICARE to see i a copy can be mailed to you.

Your Medicare appeal rightsAn appeal is the action you take i you disagree with a coverage or

payment decision by Medicare or your Medicare plan. I you decide tole an appeal, you can ask your doctor or other health care provider orsupplier or any inormation that may help your case. Keep a copy oeverything you send to Medicare as part o the appeal.

For more inormation about your Medicare appeal rights and how toask or an appeal:

Visit www.medicare.gov/publications to view the booklet MedicareAppeals. You can call 1-800-MEDICARE to see i a copy can bemailed to you.

Visit www.medicare.gov/appeals. Call 1-800-MEDICARE.
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I youre in immediate medical crisis, call 911.

For more inormation about Medicare mental health benets and coverage:

Call 1-800-MEDICARE (1-800-633-4227) to get the phone number. Y users should call1-877-486-2048.

Call your State Health Insurance Assistance Program (SHIP). Visit www.medicare.gov/contacts to get the phone number.

alk to your doctor or other health care provider i you have questions or concerns about yourmental health, to nd out more about mental health, or to nd mental health treatment. You canalso contact:

National Institute o Mental Health, National Institutes o Health:

Visit www.nimh.nih.gov.

Call 1-866-615-6464. Y users should call 1-866-415-8051.

Email [email protected].

Substance Abuse & Mental Health Services Administration (SAMHSA):

Visit www.samhsa.gov. SAMHSA has a treatment acility locator and a mental healthservices locator on its Web site.

Call 1-877-SAMHSA-7 (1-877-726-4727). Y users should call 1-800-487-4889.


Mental Health America:

Visit www.mentalhealthamerica.net.

Call 1-800-969-6642. Y users should call 1-800-433-5959.


National Alliance on Mental Illness (NAMI):

Visit www.nami.org.

Call the Helpline at 1-800-950-NAMI (1-800-950-6264). Email [email protected].

National Council or Community Behavioral Healthcare:

Visit www.thenationalcouncil.org.

Call 202-684-7457.

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Section 5: DefnitionsAppealAn appeal is the action you can take i you disagree with acoverage or payment decision made by Medicare, your Medicare healthplan, or your Medicare Prescription Drug Plan. You can appeal iMedicare or your plan denies one o the ollowing:

Your request or a health care service, supply, or prescription that you

think you should be able to get Your request or payment or health care or a prescription drug you

already got

Your request to change the amount you must pay or a prescriptiondrug

You can also appeal i youre already getting coverage and Medicare oryour plan stops paying.

AssignmentAn agreement by your doctor or other supplier to bepaid directly by Medicare, to accept the payment amount Medicareapproves or the service, and not to bill you or any more than theMedicare deductible and coinsurance.

CoinsuranceAn amount you may be required to pay as your shareo the cost or services aer you pay any deductibles. Coinsurance isusually a percentage (or example, 20%).

CopaymentAn amount you may be required to pay as your share

o the cost or a medical service or supply, like a doctors visit, hospitaloutpatient visit, or prescription. A copayment is usually a set amount,rather than a percentage. For example, you might pay $10 or $20 or adoctors visit or prescription.


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Coverage determinationTe rst decision made by your Medicare drugplan (not the pharmacy) about your drug benets, including the ollowing:

Whether a particular drug is covered Whether youve met all the requirements or getting a requested drug

How much youre required to pay or a drug

Whether to make an exception to a plan rule when you request it

I the drug plan doesnt give you a prompt decision and you can show that thedelay would afect your health, the plans ailure to act is considered to be acoverage determination. I you disagree with the coverage determination, thenext step is an appeal.

DeductibleTe amount you must pay or health care or prescriptions beoreOriginal Medicare, your prescription drug plan, or your other insurance beginsto pay.

ExceptionA type o Medicare prescription drug coverage determination. Aormulary exception is a drug plans decision to cover a drug thats not on itsdrug list or to waive a coverage rule. A tiering exception is a drug plans decisionto charge a lower amount or a drug thats on its non-preerred drug tier. Youmust request an exception, and your doctor or other prescriber must send asupporting statement explaining the medical reason or the exception.

Lietime reserve daysIn Original Medicare, these are additional days thatMedicare will pay or when youre in a hospital or more than 90 days. You havea total o 60 reserve days that can be used during your lietime. For each lietimereserve day, Medicare pays all covered costs except or a daily coinsurance.

Medically necessaryServices or supplies that are needed or the diagnosisor treatment o your medical condition and meet accepted standards o medicalpractice.

Medicare-approved amountIn Original Medicare, this is the amount adoctor or supplier that accepts assignment can be paid. It may be less than theactual amount a doctor or supplier charges. Medicare pays part o this amountand youre responsible or the diference.


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Medicare health planA plan ofered by a private company thatcontracts with Medicare to provide Part A and Part B benets to people

with Medicare who enroll in the plan. Medicare health plans include allMedicare Advantage Plans, Medicare Cost Plans, Demonstration/PilotPrograms, and Programs o All-inclusive Care or the Elderly (PACE).

Medicare Part A (hospital insurance)Coverage or inpatienthospital stays, care in a skilled nursing acility, hospice care, and somehome health care.

Medicare Part B (medical insurance)Coverage or certain doctorsservices, outpatient care, medical supplies, and preventive services.

Medicare Prescription Drug Plan (Part D)A stand-alone drugplan that adds prescription drug coverage to Original Medicare, someMedicare Cost Plans, some Medicare Private-Fee-or-Service Plans,and Medicare Medical Savings Account Plans. Tese plans are oferedby insurance companies and other private companies approved byMedicare. Medicare Advantage Plans may also ofer prescription drugcoverage that ollows the same rules as Medicare Prescription DrugPlans.

Medicare Savings ProgramA Medicaid program that helps peoplewith limited income and resources pay some or all o their Medicarepremiums, deductibles, and coinsurance.

Medigap policyMedicare Supplement Insurance sold by privateinsurance companies to ll gaps in Original Medicare coverage.

Original MedicareOriginal Medicare is ee-or-service coverageunder which the government pays your health care providers directly oryour Part A and/or Part B benets.

State Health Insurance Assistance Program (SHIP)A stateprogram that gets money rom the Federal government to give ree localhealth insurance counseling to people with Medicare.


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U.S. DEPARMEN OF

HEALH AND HUMAN SERVICES

Centers or Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, Maryland 21244-1850

Ocial BusinessPenalty or Private Use, $300

CMS Product No. 10184Revised June 2012

o get this booklet in Spanish, call1-800-MEDICARE (1-800-633-4227). Y

users should call 1-877-486-2048.

Necesita usted una copia de estagua en Espaol? Llame GRAIS al1-800-MEDICARE (1-800-633-4227).Los usuarios de Y debern llamar al1-877-486-2048.

Medicare and Your Mental Health Benefits 2012.pdf

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Transcript of Medicare and Your Mental Health Benefits 2012.pdf