By Bonnie Lane, M.S., Family Support Services.
About 15 percent of people over the age of 60 experience depression or anxiety disorders, which can damage quality of life and even shorten their lifespan because of substance abuse or other unhealthy behaviors. Older people most commonly experience General Anxiety Disorder, or GAD, but it’s often underreported and underdiagnosed, according to the Centers for Disease Control and Prevention.
Treatment for a mental illness or substance abuse disorder can easily run to the thousands of dollars, what with residential treatment, outpatient therapist appointments and expensive medications. If you have a client who is burning through assets getting treatment for themselves or a family member, you can help them by becoming familiar with what Medicare does and doesn’t cover.
Learning what mental health services are covered by “original Medicare” is as simple as going to medicare.gov and searching “mental health.” Those with Medicare Advantage plans do the same with their insurance company. Medicare Part B coverage includes psychiatrists, clinical psychologists and licensed clinical social workers, among other specialists, as well as in-patient treatment and community mental health centers.
Finding providers and facilities that accept Medicare assignment, however, isn’t as easy. Most psychologists and psychiatrists in private practice don’t accept Medicare; some don’t even accept commercial insurance. The same is true of treatment facilities. A good resource is Psychology Today, where there’s a directory of providers and facilities searchable by location, treatment specialties and insurance coverage.
When it comes to coverage, it’s important to ascertain what mental health services are needed and where they are needed. Some policies limit treatment to the policyholder’s state or immediately surrounding states.
The patient or their family needs to ask specific questions and write down the details of answers. Insurance companies are required to have advocates who work for the patient, not the company. Some are great, even advocating for uncovered services that are still necessary, and some aren’t so great, but in any case, keep their phone number handy.
Very often, I’m contacted by a family that has a loved one in crisis. In these types of cases, the affected person may need to go directly to an emergency room and receive in-patient treatment. Usually, when the patient is deemed stable and responding well to medication, they are released and instructed to continue therapy as an outpatient or in a community-based program. A three-day hospital stay makes the patient eligible for up to 100 days of rehab under Medicare, but they have to show progress in their recovery.
Speaking of medications, drugs play a big role in managing mental illness, and new ones are being approved by the Federal Drug Administration (FDA) all the time. For example, just last year, the FDA approved Cobenfy (xanomeline and trospium chloride) for the treatment of schizophrenia in adults. Only a psychiatrist, who is a medical doctor, should prescribe treatments for a mental disorder.
However, many of the new drugs come at a cost, because Tier II or Tier III medications often carry hefty copays under Medicare Part D and Medicare Advantage drug formularies, or aren’t covered at all. If a new medication isn’t affordable, a doctor may prescribe an older version or generic that isn’t as effective. Fortunately, starting this year, out-of-pocket drug costs are capped at $2,000 for Medicare recipients.
While Medicare operates the same in all states, Medicare Advantage coverage may vary based on which state the policyholder lives in. If a client becomes eligible for Medicaid – to, for example, obtain long-term care — that program is administered by the states, which also have different rules and requirements. The Knight Family Foundation provides a two-page summary of Medicaid programs in each state.
CPA advisors may not be able to diagnose a depression or anxiety disorder, but they can provide informed assistance to clients who have a loved one or who are themselves struggling with their mental health.
Bonnie Lane, M.S., is principal consultant with Family Support Services in Northbrook, Illinois, specializing in supporting families whose loved ones suffer from severe mental illness or substance addiction. Contact her at 847-651-1554 or bonnielane@thefamilysupportservices.com.
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Tags: medicare, mental health
