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For some people with disabilities, Medicare may be their best resource for health care. But if they need mental health care, they’ll find that coverage is limited. Medicare will cover only 190 days of inpatient care in a lifetime and has other limitations.
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 all ages
with a specific kidney disease
Medicare offers two
types of plans to choose from:
- Original Medicare
Plan
Hospital Insurance (Part A)
Medical Insurance (Part B)
Prescription Drug Coverage (Part D)
Medigap Insurance
OR
- Medicare Advantage
Plans like HMOs and PPOs (Part C) which can be combined with Part D.
Original Medicare Plan
Most people get their coverage through the Original Medicare Plan.
Part A (hospital)
Part A helps cover inpatient care in hospitals and some other facilities
for those who qualify.
- Most people pay
no premium for Part A, because they paid Medicare taxes while working.
Otherwise, those age 65 or older or disabled may be able to buy it.
Premiums are up to $410 per month.
- For those with
limited income and resources, their state may help pay for Part A and/or
Part B.
- Medicare Part A
covers inpatient care in a psychiatric hospital for only 190 days in
a lifetime. (There is no lifetime limit on inpatient care given in general
hospitals.) You'll pay a one time deductible of $992 for a hospital
stay of up to 60 days in each 60-day benefit period.
Part B (medical)
Part B, which is optional, helps cover services of doctors (inpatient
and outpatient), clinical social workers, psychologists and nurse practitioners;
partial hospitalization; occupational, group and family therapy; screenings
and other medical services that Part A doesn't cover.
- Benefits for mental
health services are not limited. You pay 50 percent for outpatient mental
health care that is "medically necessary," after you've paid
a $131 deductible.
- You have your choice
of doctors.
- Most people pay
a monthly premium for Part B, which is based on income. For example,
an individual earning $80,000 or less and a married person with a joint
income of $160,000 or less will each pay $93.50 per month.
- Costs for services
vary depending on the plan you choose. You may pay a coinsurance amount.
- You also pay a
deductible each year before Medicare starts to pay its share. You may
be able to get help from your state to pay this premium and deductible.
- You may choose
to have a Medigap policy that may pay some out-of-pocket costs.
- If you have limited
income, there are programs that may help pay for some health care and
prescription drugs.
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P art D (Prescription
Drug Coverage)
Plan D, which is optional, is available to everyone with Medicare, but
most people will pay a monthly premium for this coverage. Premiums vary,
but average $27 per month.
- Plans cover different
drugs, but "medically necessary" drugs must be covered.
- You pay a copayment
and, in some cases, a yearly deductible for prescription drugs. Charges
vary by plan.
- Each Medicare drug
plan has a list of covered drugs (a formulary). The list must include
at least two drugs (and in some cases all drugs) in all classes of drugs
most commonly prescribed to people with Medicare.
- If a specific drug
is not on the list of covered drugs, another drug may be substituted.
This may be a generic drug or a less-expensive therapeutic alternative
(other brand-name drug).
- Medicare is not
required to cover some drugs, such as benzodiazepines (which are prescribed
for some anxiety disorders) or barbiturates, but some plans may choose
to cover these drugs.
- Your doctor may
request an exception to these restrictions, but it may not be granted.
- People with limited
income and resources can qualify for extra help paying their Medicare
Prescription Drug Plan costs.
Medigap Insurance
Policy
You may purchase this private coverage (or an employer/union may offer
similar coverage) to fill in gaps in Part A and Part B coverage. Costs
vary.
OR
Part C
Medicare Advantage Plans like HMOs and PPOs
This option combines Part A (Hospital) and Part B (Medical). Private insurers
approved by Medicare provide this coverage. These plans generally offer
extra benefits, and many include Part D drug coverage.
- Generally, you
must see doctors in the plan.
- In many cases,
premiums (average cost $24) or costs of services (co-pays) can be lower
than for the Original Medicare Plan or the Original Medicare Plan with
a Medigap policy.
- Mental health benefits
vary by plan.
Part C + Part D
(Prescription Drug Coverage)
Most Part C plans cover prescription drugs. If they don't, you may choose
to purchase Part D coverage. See above for details.
Where can I get more
information?
Medicare or call
1-800-MEDICARE (1-800-633-4227
Social Security
or call 1-800-772-1213.
Read
an in-depth explanation of Medicare plans
Mental Health America
National Alliance of Mental
Illness
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 (Check for yourself.)
Note: A new law prohibits employer health plans from discriminating on coverage of mental health care, but the law does not apply to federally funded health care providers such as Medicaid, Medicare and the Veterans Health Administration.
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Page updated January 1, 2009 |
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