Life After 50 Expo

My wife has Original Medicare, and is currently a hospital inpatient receiving treatment for a mental health condition. Her doctor there has indicated that she might benefit partial hospitalization when she is discharged. Is this something that Medicare covers?

-Terry (Rapid City, SD)

Dear Terry,

Medicare Part B does cover 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 care, but less intensive than inpatient care.

In such a program, your wife will follow a plan of care tailored to her needs. Services may include the following:

• Individual or group therapy
• Occupational therapy
• Activity therapies such as art, dance, or music therapy, when they are used to help your wife meet the goals of her plan of care
• Prescription drugs that your wife cannot administer herself
• Training and education closely related to your wife’s plan of care
• Family counseling that primarily supports your wife’s treatment (not if it primarily promotes the wellbeing of the family)
• Services needed to diagnose your wife’s condition and evaluate her care

Partial hospitalization programs may be offered by hospital outpatient departments and by community mental health centers. Medicare will cover your wife’s partial hospitalization if both of the following apply:

• A doctor certifies that:
  • She would otherwise need inpatient treatment, or has recently been discharged from inpatient care and needs partial hospitalization to avoid a relapse in her condition.
  • And, less intensive treatment options (such as outpatient therapy) would not be enough to help her avoid hospitalization.
• She receives care from a Medicare-certified program.

After meeting the Part B deductible, your wife will be responsible for paying a percentage of the Medicare-approved amount for each service she gets from a doctor or other qualified mental health professional if the providers accept assignment. She will also be responsible for a coinsurance for each day of partial hospitalization services provided in a hospital outpatient setting or community mental health center.

If you and your wife need assistance finding a Medicare-certified partial hospitalization program, you can call 1-800-MEDICARE or visit www.medicare.gov.

-Marci

Dear Marci,

I am new to Medicare. I have been receiving treatment for depression and anxiety for several years, and have gotten treatment in both inpatient and outpatient settings. Will these services be covered under Medicare? How much will they cost?

• Beau (Baton Rouge, LA)

Dear Beau,

Medicare covers medically necessary mental health care—services and programs that are intended to help diagnose and treat mental health conditions.

If you have Original Medicare, Part A covers inpatient mental health services that you receive in either a psychiatric hospital (a hospital that only treats mental health patients) or a general hospital. Your provider should determine which hospital setting you need. If you receive care in a psychiatric hospital, Medicare covers up to 190 days of inpatient care in your lifetime. If you have used your lifetime days but need additional mental health care, Medicare may cover your additional inpatient care at a general hospital.

Be aware that you will have the same out-of-pocket costs with Original Medicare whether you receive care in a general or psychiatric hospital:

• The Part A deductible: Before Medicare covers the cost of inpatient care, you have to meet the deductible for the benefit period. In 2018, the deductible is $1,340.
• Days 1-60: After you meet the deductible, Medicare pays in full for the first 60 days of your care.
• Days 61-90: Medicare pays part of the cost, and you are responsible for a daily coinsurance. In 2018, the coinsurance is $335.
• Lifetime reserve days: For up to 60 lifetime reserve days, Medicare pays part of the cost, and you are responsible for a daily coinsurance. The coinsurance in 2018 is $670.

Medicare Part B covers outpatient mental health care, including the following services:

• Individual and group therapy
• Substance abuse treatment
• Tests to make sure you are getting the right care
• Occupational therapy
• Activity therapies such as art, dance, or music therapy
• Training and education (such as training on how to inject a needed medication or education about your condition)
• Family counseling to help with your treatment
• Laboratory tests
• Prescription drugs that you cannot administer yourself, such as injections that a doctor must give you.
• An annual depression screening that you receive in a primary care setting. Speak to your doctor or primary care provider for more information.
  • The depression screening is considered a preventive service, and Medicare covers depression screenings at 100% of the Medicare-approved amount.

Original Medicare covers these outpatient mental health services (with the exception of the annual depression screening) at 80% of the Medicare-approved amount. This means that as long as you receive services from a provider who accepts assignment (meaning they accept Medicare’s approved amount as full payment for a service), you will pay a 20% coinsurance after you meet your Part B deductible.

Medicare Part B also covers partial hospitalization for mental health treatment for people who meet coverage requirements. Partial hospitalization programs provide care that is more intensive than other forms of mental health care, but less intensive than inpatient care.

If you have a Medicare Advantage Plan, your plan must cover the same inpatient and outpatient mental health services as Original Medicare, but they may impose different rules, restrictions, and costs. If you need information about a plan’s costs and coverage rules, or if you are experiencing problems, contact your Medicare Advantage Plan.

-Marci