Life After 50 Expo

Dear Marci,

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Dear Marci,

My friend thinks she may need treatment for alcohol and substance abuse. Although she is willing to get treatment, she is worried about how much it will cost. She has Original Medicare—does Medicare cover services related to alcoholism and substance abuse?

-Gillian (Bowling Green, KY)

Dear Gillian,

Medicare covers alcoholism and substance abuse treatment in both inpatient and outpatient settings if:

  • Your friend’s provider states that the services are medically necessary
  • Your friend receives services from a Medicare-approved provider or facility
  • And, your friend’s health care provider sets up a plan of care.

Some of the services that Medicare cover include, but are not limited to:

  • Patient education regarding diagnosis and treatment
  • Psychotherapy
  • Post-hospitalization follow-up
  • Prescription drugs administered during a hospital stay or injected at a doctor’s office
    • Methadone may be covered in inpatient hospital settings, but it is not covered in outpatient clinics where it is supplied orally.
  • Outpatient prescription drugs covered by Part D
    • Part D plans must cover medically necessary drugs to treat substance abuse
      • Part D plans cannot cover methadone or similarly administered medications to treat substance abuse, but they can cover methadone for other conditions, such as pain
  • Structured Assessment and Brief Intervention (SBIRT) services provided in a doctor’s office or outpatient hospital. SBIRT is covered by Medicare when an individual shoes signs of substance abuse or dependency. SBIRT treatment involves:
    • Screening: Assessment to determine the severity of substance abuse and identify the appropriate level of treatment.
    • Brief intervention: Engagement to provide advice, increase awareness, and motivate an individual to make behavioral changes.
    • Referral to treatment: If an individual is identified as having additional treatment needs, provides them with more treatment and access to specialty care.

If your friend receives inpatient care, her care will be covered by Part A and cost-sharing rules of an inpatient hospital stay should apply. Note that if your friend receives care at an inpatient psychiatric hospital, Medicare only covers a total of 190 lifetime days. If your friend uses all 190 lifetime days but needs further inpatient care, she can get Medicare-covered care at a hospital.

If your friend receives outpatient treatment, Part Bwill cover her care. Original Medicare covers mental health services, including treatment for alcoholism and substance abuse, at 80% of the Medicare-approved amount. As long as your friend receives services from a provider who takes assignment (accepts Medicare’s approved amount as full payment for a service), your friend will pay a 20% coinsurance after she meets her Part B deductible.

If your friend is still concerned about the cost of her care, you or she can consider programs that might help her save money on her health care costs. These programs include Medicaid, the Medicare Savings Programs (MSP),  and Extra Help. To learn more about these programs and get help enrolling, you or your friend can call her State Health Insurance Assistance Program (SHIP). To find her SHIP, you can call 877-839-2675 or visit www.shiptacenter.org.

-Marci
 
 

Dear Marci,

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Dear Marci,

With Fall Open Enrollment coming up, I am thinking about changing my Medicare coverage. I might keep Original Medicare and enroll in a new Part D prescription drug plan, or I might enroll in a Medicare Advantage Plan with prescription drug coverage. What factors should I consider when I am looking at different plans?

-Eva (Topeka, KS)

Dear Eva,

Fall Open Enrollment, which runs from October 15 through December 7, is the right time to review your current coverage, compare it with other options, and possibly make changes. The last change you make during Fall Open Enrollment will take effect on January 1, 2019. To avoid enrollment problems, it is best to call 1-800-MEDICARE when making changes to your health and drug coverage.

Here are some questions to ask about any Medicare Advantage Plan that you are considering enrolling in:

  • How much are the premium, deductible, and coinsurance/ copay amounts?
  • What is the annual maximum out-of-pocket cost for the plan? This amount might be high, but can help protect you if you have expensive health care costs.
  • What service area does this plan cover?
  • Are my doctors and hospitals in the plan’s network?
  • What are the rules I have to follow t access health care services and my drugs?
  • Does the plan cover additional health care benefits that are not covered by Original Medicare?
  • How will this plan affect any additional coverage I may have?

Ask yourself these questions before choosing a Part D prescription drug plan or a Medicare Advantage Plan with prescription drug coverage:

  • Does the plan cover all the medications I take?
  • Does the plan have restrictions on my drugs (like prior authorization, step therapy or quantity limits)?
    • Prior authorization means that you must get approval from your Part D plan before the plan will pay for the drug
    • Step therapy means that your plan requires you to trey a cheaper version of the drug before it will cover a more expensive one.
    • Quantity limits restrict the quantity of a drug you can get per prescription fill, such as 30 pills of Drug X per month.
  • How much will I pay for monthly premiums and the annual deductible?
  • How much will I pay at the pharmacy (copay/coinsurance) for each drug I take?
  • Is my pharmacy in the plan’s preferred network?
  • Can I fill my prescriptions by mail order?
  • If I have retiree coverage, will the Medicare drug plan work with this coverage?

For both Medicare Advantage Plans and Part D prescription drug plans, you may also want to consider a plan’s star rating. Star ratings are quality ratings that provide a measure of a plan’s performance. Medicare scores plans in several categories, including quality of care and customer service. Ratings range from one to five stars, with five being the highest.

Keep in mind that a plan’s star rating is only one factor to review when comparing plans in your area. Even though a plan has a high star rating, it may not be right for you. It is important to see whether the plan covers the health services and drugs you need and works with the pharmacies you use before considering its star rating. Also, note that the star ratings in the Medicare & You handbook are not necessarily the most recent. For the most up-to-date, comprehensive star ratings, you should call 1-800-MEDICARE or use the online Plan Finder tool at www.medicare.gov.

You may also find it helpful to use Medicare’s Plan Finder tool, which gives you a list of Medicare Advantage and Part D plans, the drugs they cover, and their estimated costs for the year. You can access Plan Finder by going online at www.medicare.gov or calling 1-800-MEDICARE.

-Marci
 

Medicare Reminder !

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Many people are confused about which part of Medicare will cover their drugs. To answer this question, follow these general rules of thumb:

  • Part A will continue to cover the drugs you need during a Medicare-covered stay in a hospital or skilled nursing facility.
    Note: If you are getting skilled nursing care that is not covered by the Part A benefit, your drugs may be covered by the Medicare drug benefit (Part D) (if you are enrolled in a Medicare private drug plan).
  • Part B will continue to cover drugs administered by your doctor or at a dialysis facility, but the doctor or facility has to buy the drugs themselves. Part B also covers a limited number of outpatient prescription drugs, mainly certain oral cancer drugs (chemotherapy). Outpatient drugs previously paid for by Part B will continue to be paid for by Part B. Part D (see below) cannot pay for any drugs that are covered by Part B.
  • Part D covers outpatient drugs through Medicare private drug plans. If you join a Medicare private drug plan (Part D), it should cover most of the prescriptions your doctor writes for you to fill at the drug store. Check to see if your Medicare private drug plan includes the drugs you need on its list of covered drugs (formulary).

While some drugs are covered only by Part B, there are a few drugs that can be covered by either Part B or Part D depending on the circumstances.

Medicare Reminder

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Medicare covers therapy services that help you maintain your ability to function, prevent you from getting worse, or slow worsening symptoms. As long as you meet the following requirements, Medicare should cover your outpatient therapy whether or not your condition is temporary or chronic:

1. You need the technical skills of a trained therapist to provide safe and effective treatment;

2 Your doctor or therapist sets up the plan of treatment before you get care; and

3.Your doctor regularly reviews the plan of treatment to see if changes are needed.

If you have Original Medicare, Medicare Part B generally covers 80 percent of the cost of each outpatient therapy service and you or your supplemental insurance is responsible for the remaining 20 percent. In 2014, there is a $1,900 therapy cap for physical and speech therapy combined and a separate $1,900 cap for occupational therapy. However, you may be able to continue receiving therapy past the cap if it is medically necessary. If you have a Medicare Advantage plan, it can set its own cost rules for physical, occupational, and speech therapy.

Medicare Reminder

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It is very important that you review your drug plan every year. Medicare private drug plans can change their costs and the list of drugs that they cover every year.  Most people can only change Medicare drug plans during Fall Open Enrollment (sometimes called the Annual Coordinated Election Period), which runs from October 15 to December 7 each year.

Even if you are satisfied with your current Medicare coverage, you should check if there is another plan in your area that offers better coverage at a lower price. Look at other Medicare options in your area and compare them with your present coverage to see which plan will best suit your needs in the upcoming year. Research shows that people with Part D plans could lower their costs by shopping among plans each year. For example, another Part D plan in your area may cover the drugs you take with fewer restrictions and charge you less.

When choosing a Medicare private drug plan, make sure to look at all the costs, not just the premium. Your costs throughout the year will depend on what drugs you take, whether your plan covers them, and whether there are any coverage restrictions. Another plan may have lower copays, cover more of your drugs, have fewer restrictions or offer some coverage during the coverage gap.

If you are considering joining a Medicare Advantage plan to get drug coverage, remember that you will get all of your Medicare benefits from that plan. Look beyond the drug coverage; make sure the plan covers you to go to the doctors, hospitals and pharmacies you prefer to use at a cost you can afford.

Click here to read more about reviewing your choice of Part D coverage.