Behavioral Health Care Services and Medicare

Behavioral Health Care Services and Medicare

thank you so much for joining me today my name is Melissa Devine and I’m with the Medicare Medicaid assistance program through the Area Agency on Aging 1B and I am going to discuss with you today medicare’s coverage of Behavioral Health Services today we’ll learn who map is what we do what is considered Behavioral Health Care and the types of services that Medicare will cover regarding Behavioral Health Care let’s get started with the Medicare Medicaid assistance program Michigan’s Medicare and Medicaid assistance program is comprised of counselors that have been certified and have gone through extensive training in healthcare benefit counseling this includes Medicare Medicaid and other insurance products that you may encounter as a Medicare beneficiary map counselors are not connected with any insurance company and they are not licensed to sell insurance and in many states map is called the state health insurance program or ship we are located all across Michigan offering free health benefit counseling assistance with unbiased counselors so how can a map counselor help you well they can help you understand Medicare health plans they can help you compare and enroll in Medicare Advantage coverage compare or enroll in Medicare prescription drug coverage identify and Report Medicare Medicaid frauds and scams assist with enrollment into low-income programs and explain what Medicare benefits you have depending on the coverage that you have currently now let’s take a look at Behavioral Health Care first let’s define behavioral health care Behavioral Health Care is an umbrella term that refers to services and programs that are intended to help diagnose and treat both mental health illnesses and addiction related issues according to the National Alliance on Mental Illness or Nami a mental illness is a condition that affects a person’s thinking feeling or mood examples of mental illnesses include depression anxiety and schizophrenia substance use disorders and addiction do not fall under this definition of mental health illness but they are considered behavioral health conditions examples of addiction disorders include opioid use disorders oud and alcoholism it is important to note that behavioral health conditions are typically not the result of any single event or circumstance rather they tend to be complicated conditions involving an interplay of biological and environmental factors and there are several Diagnostic and treatment services that Medicare covers within Behavioral Health Care so those include inpatient and Outpatient Treatment and includes partial hospitalizations addiction recovery services medications for mental health care and opioid treatment programs we’re going to look closer at the Medicare coverage of those Diagnostic and treatment services Behavioral Health Care for inpatient and LP Medicare part A covers the inpatient mental health and addiction recovery services that are received in either a psychiatric hospital which is a hospital or distinct unit in a hospital that only treats mental health patients or it can be covered in a general hospital or inpatient Rehabilitation facility your doctor should determine which hospital setting you need and if you receive care in a psychiatric hospital Medicare will cover up to 190 days of inpatient care in your lifetime if you’ve used your lifetime days but need additional Mental Health Care Medicare May cover additional inpatient Care at a general hospital you will have the same out-of-pocket costs with original Medicare whether you receive inpatient care in a general or a psychiatric hospital that means that under part A before Medicare covers the cost of inpatient care you’ll have to meet the deductible for your benefit period and in 2023 the deductible amount is sixteen hundred dollars per benefit period now a benefit period measures your use of inpatient hospital and Skilled Nursing Facility Services and the benefit period Begins the day you’re admitted to a hospital as an inpatient and it ends the day that you’ve been out of the hospital or Skilled Nursing Facility care for 60 days in a row now when you’re admitted admitted under part a in either a general or a psychiatric hospital Days 1 to 60 of a benefit period the only out-of-pocket expense you will encounter is usually sixteen hundred dollars again because of that Medicare part A benefit period deductible now if you’re in either of those facilities longer than 60 days Days 61 to 90 of a benefit period Medicare is going to pay part of the cost but you will be responsible for a daily coinsurance charge in 2023 the co-insurance charge is four hundred dollars per day and when utilizing lifetime Reserve days you get up to 60 lifetime Reserve days Medicare pays part of the cost again leaving you responsible for daily co-insurance and in 2023 that coinsurance is eight hundred dollars per day now please note that if you enter a psychiatric hospital within 60 days of being an inpatient at a different hospital you’re still in your same benefit period and do not have to pay the part a deductible again if you have a Medicare Advantage plan your plan must cover the same mental health and addiction recovery services as original Medicare but they may impose different costs and restrictions if you need information about the cost and coverage requirements or if you’re experiencing problems contact your Medicare Advantage plan for more information Medicare Part B covers the outpatient Behavioral Health Care this includes the following Services when medically necessary and delivered by a Medicare enrolled provider you have access to individual and group therapy with a doctor or licensed related health professional you can receive treatment for substance use disorder tests that make sure you’re getting the right care occupational therapy if the main purpose is to help with treatment activity therapies such as art dance or music therapy if the main purpose is to help with your treatment training and education such as training on how to inject a needed medication or education about your condition family counseling if the main purpose is to help with your treatment laboratory tests prescription drugs that you cannot self-administer such as injections that a doctor must give you an annual depression screening that you receive in a primary care setting which you can speak to your doctor or primary care provider about for more information an annual alcohol misuse screening and if after the screening your doctor determines your misusing alcohol four brief counseling sessions per year that you receive in a primary care setting related to that alcohol and receive screening is covered at 100 percent meaning there’s no cost sharing to you if you see a provider who accepts Medicare assignment Medicare Part B also covers care that you’re going to receive in an outpatient program or to doctors or therapist office or at a clinic you may receive services from the following types of providers General Practitioners nurse practitioners physician assistants psychiatrists clinical psychologists clinical social workers and clinical nurse specialists you should make sure that any provider that you see accepts assignment to Medicare meaning that they accept accept medicare’s approved amount as full payment for service and you can avoid paying more then if you see a non-medical doctor such as a clinical psychologist or a clinical social worker it is especially important to make sure that your provider accepts Medicare payments Medicare will only pay for the services of non-medical providers if they’re signed up to accept Medicare payments Medicare Part B covers partial hospitalization for mental health treatment partial hospitalization programs offer Outpatient Care in a hospital setting on a part-time basis which can mean only during the day only at night or only during weekends partial hospitalization programs provide care that is more intensive than other forms of outpatient but they’re less intensive than an inpatient care in such a program you’ll follow a plan of care tailored to your needs Services may include the following individual or group therapy occupational therapy activity therapy such as art dance or music therapy and those are when you’re when they’re used to help you meet your goals of your plan of care prescription drugs that you cannot administer yourself training and education closely related to your plan of care family counseling that supports your treatment and well-being and other services that are needed to diagnose your condition and evaluate your care partial hospitalization programs may be offered by Hospital outpatient departments and by Community Mental Health Centers Medicare covers your partial hospitalization care if both of the following occurs a doctor certifies that you would otherwise need inpatient treatment or you have recently been discharged from an inpatient care and need partial hospitalization to avoid a relapse in your condition and less intensive treatment options such as Outpatient Therapy would not be enough to help you avoid hospitalization now you will want to make sure that you receive your care from a Medicare certified program take a look at addiction recovery services Medicare covers treatment for alcoholism and substance use disorders in both inpatient and outpatient settings if your provider states that the services are medically necessary you receive services from a Medicare approved provider or facility and your provider sets up your plan of care covered Services include but are not limited to patient education regarding diagnosis and treatment psychotherapy post hospitalization follow-up opioid treatment programs are OTP services from FDA approved Opa treatment medications like methadone buprenorphine Naltrexone and dispensing administering the drug as ex as applicable substance use counseling either in individual or group therapy with toxicology testing intake activities and periodic assessments prescription drugs administered during a hospital stay or injected at a doctor’s office and methadone may be covered in inpatient Hospital settings outpatient prescription drugs covered by Part D party plans must cover medically necessary drugs to treat substance use disorders party plans cannot cover outpatient methadone or similarly administered medications to treat substance use disorders but they can cover Methadone for other conditions such as pain now note that opioid treatment programs can provide Methadone for substance use disorder treatments but there’s also coverage for structured assessment and brief interventions or sbirt services that are provided in a doctor’s office or outpatient hospital the sbirt programs are covered by Medicare when an individual shows signs of substance use disorder or dependency treatment involves a screening or an assessment to determine the severity of the substance use disorder and identify the appropriate level of treatment brief intervention engagement into and to provide advice increase awareness and motivate the individual to make behavioral changes and a referral to treatment if the individual is identified as having additional treatment needs we want to make sure that you have access to that so this provides you with more treatment and access to Specialty Care part A covers your care if you are hospitalized and need treatment for substance use disorders cost sharing rules for an inpatient Hospital stay are as they were before again with original Medicare you have that benefit period deductible for part A of sixteen hundred dollars if you need to be in an inpatient setting longer than 60 days you can expect to pay a portion that is a 400 co-insurance per day from Days 61 to 90. and if you need to utilize your lifetime Reserve days up to 60 Medicare pays a part of it again but leaving you with an 800 co-insurance per day now note If you’re receiving care in an inpatient Psychiatric Hospital keep in mind that Medicare only covers a total of 190 lifetime days and if you have a Medicare Advantage plan you should have access to the same coverage under potentially different cost sharing information so for more information on that you would want to speak with your Medicare Advantage plan directly now when it comes to outpatient care Part B covers that outpatient care for substance use disorders that you’re going to receive in a clinic a hospital outpatient department or even an opioid treatment program please note that some substance use disorder treatments can also be provided using technology services like Telehealth but original Medicare covers mental health services including treatment for alcoholism and substance use disorders at an 80 percent of Medicare approved amounts so as long as you receive the service from a participating provider or one who takes assignment of Medicare you will owe a 20 co-insurance after you’ve met Your Part B deductible if you’re enrolled in a Medicare Advantage plan you should contact your plan for cost and coverage information about treatment for substance use disorder your plans deductibles and co-payments or coinsurances will apply now with original Medicare again the out-of-pocket expenses are similar to what we discussed earlier the part B deductible for 2023 is 226 annually so once that’s met Medicare will pay 80 percent of the Medicare approved Services amounts and you would be responsible for a 20 co-insurance to get Medicare prescription drug coverage you must be enrolled in a Medicare parts Part D prescription drug plan Part D is offered through private insurance companies either as a standalone plan or for those that have a Medicare Advantage plan it is included as a set of benefits party plans vary in cost and in the specific medications that they cover but each plan has a list of covered drugs called a formulary you should be able to check before joining that part D plan to ensure that any drugs that you need are on that plan’s formulary if your drug is not on the formulary you may have to request an exception or pay out of pocket or file an appeal to ask your plan to cover the med while Part D plans are not required to cover all drugs they are required to cover all antidepressant anticonvulsant and antipsychotic medications with limited exceptions some medications that are used to treat substance use do not meet certain requirements for coverage under Medicare Part D these medications can be covered by part A during an inpatient stay or by Part B as part of a medication assisted treatment or mat at an opioid treatment program or OTP now let’s take a look at the opioid treatment programs or otps Medicare Part B covers opioid use disorders or oud treatment received at opioid treatment programs opioid treatment programs which are also known as methadone clinics are certified by the Substance Abuse and Mental Health Service administrations or samhsa to provide methadone as part of a medication assisted treatment otps are the only place where an individual can receive methadone to treat opioid use disorder in order to receive Medicare coverage for OTP services the OTP must be certified by samsa and enroll in the Medicare program once an OTP program is enrolled in Medicare it can Bill Medicare for the services provided to you therefore if you want to get Medicare covered OTP Services you should contact the optp to make sure that they accept Medicare if the OTP is not enrolled in Medicare you are responsible for the cost of your care if you have both Medicare and Medicaid and were previously receiving Medicaid covered OTP Services Medicaid should continue to pay primary for treatment until the OTP is enrolled in Medicare at this time once you meet your deductible you will not owe any cost sharing coinsurance or co-payment for the OTP in original Medicare again for specifics on the coverage under a Medicare Advantage plan you’ll want to reach out to your specific Medicare Advantage plan for details a drug Management program is a tool that party uses and limits at-risk beneficiaries access to certain drugs plans use clinical guidelines to identify beneficiaries who are at risk for misuse or abuse of frequently abused drugs such as opioids at-risk beneficiaries may be required to use one provider and or One Pharmacy to get flagged medications this is known as a pharmacy or provider lock-in and if it if an at-risk beneficiary has extra help an assistance program that helps pay for medication costs they cannot use the extra help special enrollment period to make changes to their coverage normally those that have extra help are entitled to a special enrollment period that allows most beneficiaries with extra help to change their coverage up to once per calendar quarter during the first three quarters of the year if a beneficiary is found to be at risk though their plan must send two notices the first notice declares the beneficiary potentially at risk it’s going to include the plant’s proposed coverage limitations such as a pharmacy lock-in it’ll include information on any limitation on the availability of the extra help SCP if relevant to the beneficiary a time frame for the plan’s decision and the beneficiary has 30 days to submit relevant information for example information about why they may be exempt from the lock-in to the plan they also May submit Pharmacy or prescriber preferences in the case of a proposed lock-in and the second notice declares the beneficiary at risk and gives them the option to select provider and Pharmacy preferences as well as to appeal for redetermination the review is a check that a plan and or pharmacist may do if you fill a prescription for certain medications such as an opioid pain medication the safety review must be for potentially unsafe opioid amounts opioid use with benzodiazepines and new opioid use in which case you may be limited to a seven day supply or less if your pharmacist cannot fill the prescription because it is deemed unsafe the pharmacist should give you a notice about how to request a coverage determination from the plan requesting a coverage determination is the first step that you must take before beginning the appeal process if the plan denies coverage you can begin an appeal to ask your plan to cover the drug if possible you should contact your doctor for support with an appeal now let’s take a look at Medicare wellness and preventative Services Medicare Part B covers preventative Services like screenings and exams Wellness visits lab tests immunizations to help prevent find and manage medical problems preventative Services may find health problems early when treatment works best you must have Medicare Part B for Medicare to cover these services these services are covered no matter what kind of Medicare health plan you have however the rules for how much you pay for these Services may vary talk with your doctor about which preventative Services you need how often you may need them to stay healthy and if you meet the criteria for coverage based on your age gender and medical history the Medicare renew handbook provides more details as well for a list of common Part B covered services and included guidelines for who’s covered and how often Medicare will pay these Services view Pages 30 to 54 in the Medicare and you handbook from 2023. preventative service costs under original Medicare when you’re under original Medicare you’ll pay nothing for most preventative Services if you get the services from a doctor or other provider who accepts assignment for some Medicare preventative Services you will pay nothing for the service but may have to pay a co-insurance for the office visit itself when you get the services if you’re in a Medicare Advantage plan or other Medicare Plan and get Medicare covered preventative Services you may have different cost sharing all new to Medicare individuals get a welcome to Medicare visit free one time with their doctor it’s a great way to get up to date on important screenings and shots and review medical history now this is not a complete physical which may incur other charges be welcome to Medicare visit is only offered within the first 12 months of getting Medicare Part B but during the exam the doctor will review the following with you medical and social history height weight body mass index blood pressure even a simple vision test potential risk factors for depression a review of functional ability and the level of safety which means an assessment of hearing impairment the ability to sex successfully perform activities of daily living fall risk and home safety individuals will also get advice to help them prevent disease improve health and stay well they should also get a brief written plan like a checklist letting them know if any additional screenings or preventative Services are needed and at this visit the doctor may also refer you for additional Medicare covered screenings if the referral is a result of the initial welcome to Medicare visit there is no cost if the doctor accepts Medicare assignment and this is a great benefit that people really should take advantage of now Medicare also covers a yearly Wellness visit after you’ve had your part B for longer than 12 months you get access to an annual Wellness visit to develop or update a prevention plan just for you Medicare covers one annual Wellness visit every 12 months from your welcome to Medicare visit during the visit your doctor will record your blood pressure height and weight measurements review for your potential risk factors of depression review your functional ability and level of safety meaning that hearing impairment assessment the ability to successfully perform activities of daily living fall risk and home safety they’ll even give you advice to help you prevent disease improve your health and stay well you’ll get a brief written plan like a checklist letting you know which screenings and other preventative Services you need over the next five to ten years you don’t necessarily need to get your welcome to Medicare visit before getting your annual Wellness visit but if you choose to get that welcome to Medicare visit you have to wait a full 12 months before you can get your first annual Wellness visit again you’ll pay nothing for this exam if the doctor accepts assignment to Medicare now let’s take a look at programs that can help save you money there are programs available to help people with limited income and Resources pay their Medicare costs these include Medicaid extra help the Medicare Savings programs and more if you think you might qualify or need help call map we’ll set up some time to have a private appointment with you and review what programs you may be eligible for and a quick word about Medicare fraud answers outpatient Medical Health Care fraud occurs when Medicare is billed for mental health care services that you did not receive you can report fraud or errors to your senior Medicare Patrol or s p map is your senior Medicare Patrol or s p and you can report the Fraud and Abuse to us directly give us a call at 800-803-7174 if you feel that you may be a victim of Fraud and Abuse or know someone who has been but definitely report potential outpatient Mental Health Care fraud errors or abuse especially if you spend the day at a facility playing games or watching TV and Medicare is then billed for group psychotherapy or you and other beneficiaries are picked up by a bus or van taken for a meal and then Medicare gets billed for psychiatric evaluations if you see other incorrect charges on your Medicare summary notice or explanation of benefits such as mental health services in Access of what you received or that you never even received and did you know that map is a part of the Area Agency on Aging 1B at the Area Agency on Aging 1B we help seniors and those that are disabled throughout a six County region serving Livingston Macomb Monroe Oakland Sinclair and Washington counties you can contact the Area Agency on Aging 1B through our website at www.aa the number one B dot org or calling 800 852-7795 the Area Agency on Aging 1B offers programs that can help in with information and assistance they have free phone helpline for seniors and their families they can help guide seniors and family members on understanding Home and community-based Services and can be your first place to call when you or a loved one needs assistance map is here to help you if you want to speak with a map counselor about your specific situation give us a call our service is confidential and unbiased we counsel currently over the phone zoom and in person where available no question is too trivial and we often deal with a very complicated questions as well for resources outside of map you have access to the Medicare and you book which is delivered in the fall but you have access to an electronic version all year long online you also have access to medicare’s website medicare.gov or calling Medicare directly at 1-800 Medicare but for your most up-to-date information in your area give map a call at 800-803-7174 our counselors are unbiased they provide free services and are certified and are not sales agents so we’re not affiliated with any private insurance companies we can be your best resource for all questions and concerns Medicare no question is too small or difficult and we’ve saved over two million dollars for beneficiaries in your area alone and this is just a brief funding statement from our funders through s p and the ship programs and if you have any questions today on anything that we discussed please feel free to reach out to me my name is Melissa Devine again my email is m Divine at AAA the number one B dot org thank you so much for spending your time with me today and have a wonderful day

Join MMAP for the Behavioral Health Care Services and Medicare program. This program goes over what behavioral health services are and how they are covered under Medicare.