Medicare Adds New Mental Health Coverage in 2014,
Explains Marci’s Medicare Answers
Marci’s February Q&A also has solutions for seniors
with new Medicare drug plans in 2014
Feb. 13, 2014 – There is new coverage from Medicare
in 2014 for outpatient mental health visits that Marci explains in this
February issue of Marci’s Medicare Answers.
senior writes in who joined a new Medicare prescription drug plan, only
to find a prescription he needs is not covered. Marci has good news on
this one, too.
I switched to a different Medicare prescription
drug plan during the Fall Open Enrollment Period in 2013. Unfortunately,
a drug that I had been taking regularly since 2010 will not be covered
by my current drug plan. Is there any way I can get my drug covered by
my current plan? —Roscoe
Yes. If your new Medicare prescription drug plan,
also known as a Part D plan, does not cover a drug that you had already
been taking, your plan should provide you with a 30-day transition fill
at some time during the first 90 days of the year.
A transition fill is a one-time, 30-day supply of a
Medicare-covered drug that Medicare prescription drug plans must cover
when you’re in a new plan or when your existing plan changes its
coverage. Note that transition fills are not for new prescriptions. In
order to get a transition fill, you must have been taking the drug
before switching your Part D coverage or before your existing plan
changed its drug coverage.
In addition to providing you with the transition
fill, Part D plans must also give you a transition notice explaining
that you are currently using your transition fill and informing you of
your appeal rights. If your drug is covered on your new Part D plan’s
list of covered drugs (i.e. formulary), but the plan has imposed
coverage restrictions on the drug (e.g. step therapy or prior
authorization), your plan must give you a 30-day transition fill without
restrictions during the first 90 days you are enrolled in the plan.
Note that getting a transition fill is a temporary
solution. In order to ensure that you are able to get your drugs
throughout the year, you should contact your doctor right away. Ask your
doctor if he/she can make an exception request to your plan and formally
ask your new plan to cover your drug so that your drug can be covered
throughout the year. Also, consider talking to your doctor about
switching you to a drug that your plan does cover.
Friends have told me that Medicare now covers
mental health care in the same way that it covers other types of health
care. Is this true? —Suzanne
Yes. In 2013, Original Medicare, the traditional
Medicare program administered by the federal government, covered 65
percent of the cost of the Medicare-approved amount for outpatient
mental health visits. In 2013, people with Original Medicare insurance
were responsible for the cost of the remaining 35 percent coinsurance if
they did not have any sort of Medigap supplemental insurance to pay for
In 2014, Original Medicare began covering 80
percent of the cost of the Medicare-approved amount for outpatient
mental health visits in the same way that it covers 80 percent of the
Medicare-approved amount for most outpatient services.
Keep in mind, however, that Original Medicare has
not changed how it covers inpatient mental health services. If you
receive care in a psychiatric hospital, Medicare covers up to 190 days
of inpatient care in one lifetime. After you have reached that 190-day
limit, Medicare may pay for mental health care at a general hospital.
Your inpatient psychiatric hospital costs will be the same as the
inpatient hospital costs you pay under Original Medicare Part A, the
hospital insurance part of Medicare.
If you have a Medicare Advantage plan, also known
as a Medicare private health plan, know that different costs and rules
may apply. Contact your plan directly to learn more about your plan’s
coverage of outpatient mental health benefits.
I received a notice in the mail from the Centers
for Medicare & Medicaid Services. This notice is telling me that the
Medicare Advantage plan I’ve enrolled in is a consistently
low-performing plan. What does this mean? — Marcia
In early February, the Centers for Medicare &
Medicaid Services (CMS) sends notices to people who have recently
enrolled in a consistently low-performing Medicare Advantage or Part D
plan. CMS will send this notice to you if your plan has received an
overall Medicare star rating of less than three stars for three
Medicare star ratings are quality ratings for
Medicare Advantage and Part D plans. Each year, Medicare scores how well
plans perform in several categories, including quality of care and
customer service. Star ratings range from one to five stars, with five
being the highest score and one being the lowest score. Medicare also
assigns plans one overall star rating to summarize the plan’s
performance as a whole.
If you have received this notice, you are entitled
to a Special Enrollment Period (SEP) to disenroll from the
low-performing plan and enroll into a Medicare Advantage or Part D plan
with an overall star rating of three stars or more. You will be able to
make this switch once at anytime during the rest of the year. To use
this SEP, you will need to call 800-MEDICARE directly.
If you do not want to make any changes and you want
to stay in your current plan, you will be allowed to do so; however, you
should make sure that the plan’s costs, coverage benefits and rules will
best meet your individual needs for the remainder of the year.
Lastly, keep in mind that people with Medicare are
also allowed an SEP to enroll into a five-star Medicare Advantage plan
or Part D plan once each calendar year. In order to use this SEP, the
plan must have an overall five-star rating and must be offered in your
service area. Note that this five-star SEP is separate from the SEP you
are entitled to if you are in a consistently low-performing plan.
To learn more about a particular plan’s star rating
or to locate higher quality plans in your area, you can call
800-MEDICARE or go online and visit www.medicare.gov/find-a-plan.
Marci’s Medicare Answers is a service of the
Medicare Rights Center (www.medicarerights.org), the nation’s largest
independent source of information and assistance for people with
Medicare. To subscribe to “Dear Marci,” MRC’s free educational
e-newsletter, click here.
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