About 15% of people over the age of 60 experience depression or anxiety disorders. These conditions can damage their quality of life and even shorten their lifespan because they’re often accompanied by substance abuse or other unhealthy behaviors. Older people most commonly experience general anxiety disorder (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 into thousands of dollars, between residential treatment, outpatient therapist appointments and expensive medications. If you have a client who is burning through assets getting treatment for themself or a family member, you can help them by becoming familiar with what Medicare does and doesn’t cover.
What to Research
Learning which 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 can do the same with their insurance company. Medicare Part B coverage includes psychiatrists, clinical psychologists and licensed clinical social workers, among other specialists. Part B also covers in-patient treatment and community mental health centers.
Finding providers and facilities that accept Medicare assignment, however, isn’t as easy. Studies have found that people seeking mental health care carry a significant “cash burden.” That’s because about half of psychologists and psychiatrists in private practice don’t participate in insurance plans. The professionals likely to accept Medicare and private insurance tend to be in group practice or affiliated with hospitals.
Medicare recipients can search Medicare.gov or their Medicare Advantage website to find in-network providers, but those listed may not have appointments available. Two other resources are Psychology Today and GoodTherapy.org. Both websites include directories of providers and facilities searchable by location, treatment specialties and insurance coverage. Each website charges therapists a monthly fee of $30 to $50 for includion in their directories.
Not a One-Size Solution
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 the immediately surrounding states.
The patient or their family needs to ask specific questions and write down the detailed answers to these questions. For example, Do I have residential coverage? Do I have intensive outpatient or partial hospitalization coverage? Are there in-network facilities out-of-state? What is my out-of-pocket maximum?
Most insurance companies have ombudsmen and advocates who can provide help navigating treatment choices. Call the customer service number on the back of the insurance card to get connected. Medicare has a Medicare beneficiary ombudsman as well, but it’s recommended that patients or families first contact their provider.
Some advocates 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.
Rehab Eligibility Under Medicare
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.
A Word on Drugs
Drugs play a big role in managing mental illness, and the U.S. Food & Drug Administration is approving new drugs 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 they 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.
Who’s In Charge
While Medicare operates the same in all states, Medicare Advantage policies vary based on which state the policyholder lives in. And if a client becomes dual-eligible for Medicare and Medicaid — for example, to obtain long-term care — that can be complicated. That’s because Medicaid is administered by the states, which also have different rules and requirements. KFF, formerly known as the. Kaiser Family Foundation, provides a two-page summary of Medicaid programs in each state.
Financial 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, MS, is principal consultant with Family Support Services in Northbrook, Ill. Bonnie specializes in supporting families whose loved ones suffer from severe mental illness or substance addiction. Contact her at 847-651-1554 or bonnielane@thefamilysupportservices.com.
