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Medicare and mental health care

If you have a disability, Medicare may be your best resource for health care. Many individuals who have psychiatric disabilities are on Medicare because they receive Social Security Disability Insurance. Recent health care reform legislation has improved coverage.

The Original Medicare Plan is a fee-for-service insurance program managed by the Federal Government and is for:

  • people age 65 or older,
  • people under age 65 with certain disabilities, and
  • people of any age with a specific kidney disease

Medicare offers two types of plans to choose from:

  1. Original Medicare Plan, which includes:
    Hospital Insurance (Part A)
    Medical Insurance (Part B)
    Prescription Drug Coverage (Part D)
    Medigap Insurance
    OR
  2. Medicare Advantage Plans (like HMOs and PPOs) Part C, which can be combined with Part D.

Original Medicare Plan
Most people choose to get their coverage through the Original Medicare Plan. If you’re already getting benefits from Social Security, in most cases, you will automatically get Part A and Part B, either when you turn 65 or receive disability benefits from Social Security for 24 months.

If you aren’t getting Social Security or RRB benefits (for instance, because you’re still working) and you want Part A or Part B, you will need to sign up.

Medicare Part A: Hospital Insurance
Part A helps cover inpatient care in hospitals, skilled nursing facilities, hospice, and home health care. Mental health hospital services are covered the same as any other hospital services. Part A covers a semi-private room, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies.

How much is my Part A premium?
Most people don’t pay a monthly premium for Part A coverage because they or their spouse have 40 or more quarters of Medicare-covered employment. Others, who qualify, will pay $248-$450 per month.

In most cases, if you choose to buy Part A, you must also have Part B and pay monthly premiums for both. If you have limited income and resources, your state may help you pay for Part A and/or Part B.

What are my out-of-pocket costs with Part A?
For each benefit period, if you are hospitalized, Medicare Part A pays all covered costs after you have paid a deductible of $1,132 (2011) during the first 60 days. For longer stays, you will pay out-of-pocket amounts of:

  • $283 per day for days 61-90.
  • $566 per day for days 91-150.
  • All costs for each day beyond 150 days

Medicare Part B: Medical Insurance
Part B helps cover doctors’ services and tests, hospital outpatient care, and home health care. It covers the doctor’s services you get while you’re in a hospital. It now provides a free annual wellness checkup and covers many preventive services. You can go to any doctor, supplier, hospital, or other facility that is enrolled in Medicare and is accepting new Medicare patients.

Mental health coverage: Part B helps cover visits with a psychiatrist or other doctor, visits with a clinical psychologist or clinical social worker, and lab tests ordered by your doctor. Part B may also pay for partial hospitalization services. Note: Inpatient mental health care is covered under Part A hospital stays.

With a few exceptions, most prescriptions aren’t covered under Original Medicare. You can add comprehensive drug coverage by joining a Medicare Prescription Drug Plan (Part D) – see below.

How much is my Part B premium?
Most beneficiaries (those with incomes of $85,000 or less or $170,000 or less for joint filers) will pay a $96.40, $110.50 or $115.40 premium in 2011. Those with higher incomes may pay more.

What are my out-of-pocket costs with Part B?
You pay a deductible of $162.00 per year, then 20% of the Medicare-approved amount for most services. But for out-patient mental health treatment, such as counseling or psychotherapy, in 2011 you will pay 45% of the Medicare-approved amount. This percentage will decrease over the next 3 years.

Medicare Part C: Medicare Advantage Plans (like an HMO or PPO)
These are health plans run by Medicare-approved private insurance companies. Medicare Advantage Plans (also called “Part C”) include Part A (hospital insurance), Part B (medical insurance), and usually other coverage like Part D (prescription drug coverage) sometimes for an extra cost.

In most plans, you need to use plan doctors and hospitals or you may pay more or all of the costs. You usually pay a monthly premium (in addition to your Part B premium) and a copayment or coinsurance for covered services. Costs, extra coverage, and rules vary by plan.

Medicare Part D: Prescription Drug Coverage
In Original Medicare, if you don’t already have other prescription drug coverage, you must join a Medicare Prescription Drug Plan. These plans are available through private companies under contract with Medicare. Costs vary.

Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. The Affordable Care Act will provide assistance to people who are in the donut-hole coverage gap. Effective in 2011, if you reach the coverage gap, you will get a 50% discount on covered brand-name prescription drugs at the time you buy them. The discount will increase over the next nine years. Rules and restrictions may apply.

Medigap (Medicare Supplement Insurance) Policies
Original Medicare pays for many, but not all, health care services and supplies. A Medigap policy, sold by private insurance companies, can help pay some of the health care costs (“gaps”) that Original Medicare doesn’t cover, like copayments, coinsurance, and deductibles.

Medicare Low-Income Assistance
State Medicare Savings Programs:

States have programs that pay Medicare premiums and, in some cases, may also pay Part A and Part B deductibles, coinsurance, and copayments.
People with limited income and resources may qualify for Extra Help paying their Medicare prescription drug coverage costs.

To enroll or change your Medicare plan
You may enroll in 2011 plans or change your plan between November 15, 2010 and December 31, 2010; during other periods for the Medicare Advantage Plan.

Consumer warning:
AARP warns that some unscrupulous salespeople are peddling Medicare insurance. Do not buy from anyone who rushes you into deciding, has come to your home uninvited or tells you all doctors will accept the plan.

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