Medicare and the Health Insurance Marketplace and Medicare Coverage for Mental Health Services


Coordinator: Welcome and thank you for standing
by. For the duration of today’s call all participants will be on a listen-only mode.
During the question and answer session if you would like to ask a question please press
star 1 on your touchtone phone. Today’s call is being recorded – should you have any
objections you may disconnect at this time. I would now like to hand the call over to
Miss (Alicia Mcentire). Miss (Mcentire) you may begin. (Alicia Mcentire): Thank you. Thank you everyone
for joining today. My name is (Alicia Mcentire). I’m a Public Health Analyst with SAMHSA
and in my role here I serve as a Special Assistant for Health Reform and Health Care Financing
within SAMHSA’s Center or Substance Abuse Treatment. SAMHSA would like to express our
sincere thanks for CMS for this important opportunity for collaboration. Increasing
access to insurance coverage, especially for populations with behavioral health needs,
is a shared goal of SAMHSA and CMS. Before we continue I do just want to add the
following disclaimer. This CMS National Training Program product is not a legal document. Official
legal guidance is contained in the relevant statutes, regulations and rulings. So I’d like to just – before I turn it over
to our speaker today I would like to just talk for a minute about substance use and
mental illness in the US. Behavioral health issues affect millions of adults each year.
Findings from the National Survey on Drug Use and Health found in the past year that
1 in 12 adults had a substance use disorder and 1 in 5 adults had a mental health issue.
Many of these adults do not have health insurance despite their eligibility for Medicaid or
other assistance in the health insurance marketplace. The Affordable Care Act presents a variety
of options to help individuals with behavioral health conditions access health insurance
and many for the first time, however, recent reports have shown that many of the currently
uninsured are still unaware of this year’s open enrollment period and the potential opportunities
available in the marketplace. Because health insurance is vital to helping
individuals maintain optimal health SAMHSA along with our federal partners, especially
CMS, are focusing efforts on education and outreach to insure diverse populations are
aware of their insurance options. Now today’s webinar builds on previous work undertaken
by SAMHSA, including developing toolkits, education campaigns, technical assistance
and engaging in social media efforts. More information on this can be found at SAMHSA.gov.
Now I’d like to introduce (David Santana). (David) is a Health Insurance Specialist at
the Centers for Medicare and Medicaid Services – CMS. (David) serves as subject matter expert
and lead trainer for the National Training Program Division in the Office of Communications.
In this role he is responsible for effectively developing educational materials and communicating
information about CMS programs and resources to CMS stakeholders. In addition (David) provides
technical assistance concerning CMS program policies to governmental entities at the federal
and state level as well as local agencies and organizations. I’d like to welcome (David). (David Santana): Thank you and welcome everyone
and thanks again for giving us the opportunity to partnership and bring you some valuable
information that may serve you to council those who relied upon you for assistance and
to make informed health care decisions. We are at slide number 3 and we’re going to
start this presentation focusing on individual marketplace and those individuals who are
either have Medicare or may soon be eligible to get Medicare. So we’re going to tell
this individual what they need to know and, again, at the end of the day we just want
them to have the information so they can make an informed health care decision. We also are going to – I’m going to tell
you a little bit about when they may get coverage in the marketplace and when they can’t with
regard to those with Medicare and also we’re going to touch a little bit on those who are
faced with the decision with regard to Medicare with the decision on whether or not they should
enroll in the Medicare Prescription Drug Plan. Next slide, which is titled Medicare and the
Marketplace. So we’re going to start with – we’re going
to start the presentation by bringing up four main points. And these are four main messages
that we can get across to individuals in Medicare. The first one is that Medicare is not a part
of the Healthy Children’s marketplace. So that’s the first thing and there are many
many individuals who are asking questions in terms of their Medicare and the marketplace.
This year we are expecting to have about 54 million individuals in the Medicare program.
By 2030 we’re going to have about 80 million individuals enrolled in the Medicare program
by itself. So that’s telling you that we will have
many individuals aging into the Medicare rapidly for the next few years. So it is vital that
we have the basic information these individuals need so they can make an informed choice when
the time comes. So the second message is if you have Medicare
you’re covered. Generally if you have Medicare you’re covered and you don’t need to do
anything related to the marketplace and I say generally because we’re going to look
at other situations that individuals and Medicare may have when they may need to look at the
marketplace to make sure that they have a comprehensive coverage. Now Medicare does
not offer Medicare supplement insurance, also called (unintelligible) – Medicare Part B
plans or Medicare Advantage plans. So many of these companies are offering private
health insurance in the marketplace they may have products across markets from Medicare
to Medicaid to the private health insurance and even through employer plan. However, those
plans there are offered through the Medicare program are not part of the marketplace. And
instead we direct those individuals to go to Medicare.gov website to find, compare and
enroll in Medicare Advantage plans, part D plan and also look up medical policy and contact
those policies if they would like to enroll in a Medicare supplement plan. The last point we wanted to call to your attention
is that even if an individual is already enrolled in Medicare whether they are – they have Part
A, which is hospital insurance or Part B it is against the law for someone who knows that
these individuals enrolled in Medicare to sell them a marketplace plan. Next slide,
slide number five. So we’re going to start by talking about
those individuals who are already enrolled in Medicare. As I mentioned people with Medicare
usually have what we call minimum essential coverage. So as we probably are aware by now
those individuals in 2014 that do not have minimum essential coverage, such as Medicare
Part A, don’t qualify for an exemption in the marketplace they may have to pay a fee
when they file their taxes the following year because they didn’t have minimum essential
coverage or they don’t qualify for an exemption. So Medicare Part A, which is the hospital
insurance part of Medicare and is a part of coverage when an individual becomes an inpatient
in a hospital is considered in the law minimum essential coverage. Those individuals also
enrolled in a Medicare Advantage plan in case anyone asks those plans are also minimum essential
coverage. Now there are for the majority of individuals in Medicare, in fact, 99% of them
do qualify for premium free Medicare Part A. That is because they work or there’s
past work and pay into a social security system and have the required amount of quarters – years
of work accumulated to get – or to be entitled to Medicare Part A without having to pay a
premium. Now Medicare Part B on the other hand is not
an entitlement program. You are not entitled to get Part B because you don’t pay into
the system to get Part B and therefore it is voluntary for individuals to sign up. Medicare
Part B is for doctor services and outpatient settings, laboratory tests, (unintelligible)
medical equipment and so forth. Now there are – or there is a 1% of individuals in Medicare
that do not qualify for premium free Medicare Part A. Those individuals, about 1% of them,
may only enroll in Medicare Part B because they either can’t afford the premium for
Medicare Part A or they simply do not want to get the hospital part. If they only have
Part B – Part B by itself is not considered minimum essential coverage and that is why
I mentioned in the previous slide that if an individual is in that situation they may
want to look to the marketplace to see if they can dis-enroll from Medicare Part B and
then choose a plan in the marketplace because, again, Part B by itself is not considered
a minimum essential coverage. So with that there are many individuals who
are – who retired before age 65 and those individuals may use the marketplace to buy
a plan that meets their needs. So depending on their income and family size they may be
able to get lower cost in the monthly premiums and out of pocket costs. When they apply for
coverage in the marketplace they also find out, of course, if they may be eligible for
Medicaid. The Medicare annual open enrollment is not
the same as the marketplace open enrollment period that is happening right now. The Medicare
open enrollment period is from October 15 through December 7 and this is the opportunity
for individuals in Medicare, for example, who want to enroll in a Medicare Advantage
plan or to want to enroll in a Medicare Part B plan or if they have their plan this is
their opportunity to go in and choose a different plan. It’s kind of similar to the plans
in your marketplace. So, again, there is a difference between Medicare open enrollment
period and the marketplace open enrollment period. Next slide, slide number 6. So those individuals who are not yet enrolled
in Medicare, say they are enrolled in the marketplace plan and they are mainly aging
into Medicare. So Medicare is for individuals when they turn 65 because of age and over,
those who have certain disabilities and apply and receive social security disability benefits
and those who have or develop stage five of (unintelligible). So this slide is just mainly
looking at those individuals who have a marketplace plan and are aging into Medicare. So they
may only have two choices. They have the choice, for example, to take
the Medicare Part A and B and cancel their marketplace plan as soon as the Medicare takes
effect. Now the second option is that they could, of course, keep their Medicare plan
and they also keep their marketplace plan. Keeping in mind that those individuals who
decide to keep their marketplace plan when they age and they get enrolled into Medicare,
if they were receiving any financial assistance that financial assistance would be terminated
upon eligibility for Medicare part A. Those individuals who, for example, decide
or who do not get enrolled in Medicare automatically they need to keep in mind that there is a
window by which they have to obey if they want to access Medicare, specifically their
seven month window around their 65th birthday to sign up for Medicare. Three months before,
the month and then three months after. Those individuals who do not get automatically enrolled
in Medicare and decide not to enroll in Medicare during that time it is important to remind
them that they may face a late enrollment penalty specifically for Medicare Part B if
that’s the part they’re not entitled if they decide to enroll later. Next slide, slide
number seven, choose a market place plan instead of Medicare. Let’s focus here on three different groups
of individuals in terms of how they get enrolled in Medicare. The first one I mentioned it
is that 1% of individuals out there that do not qualify for premium free part A because
themselves or their spouse did not have the required amount of credit in the system. So
even individuals out there in this situation they could keep their marketplace plan after
they age into Medicare, they don’t have to enroll in Medicare and they still qualify
for premium tax credit if that’s the way they want to go. If those individuals are currently enrolled
in Medicare Part A and B they could also dis-enroll from Medicare Part A and B and instead choose
the marketplace plan and they could qualify for premium tax credit. So this is the only
group of individuals who really have the option to pick between the marketplace plan and Medicare
and be able to keep the premium tax credit. Now the second group, as I mentioned, are
those who have end stage renal disease. So they have a medical condition that would qualify
them to get Medicare and individuals in this group could be at any age. So it could be
a child, it could be a young adult, it could be anyone who is – who developed end stage
renal disease. They could get Medicare through either their own work history or for a (unintelligible)
through (AS Powers) or in case of a child they can get it through a work history of
their parents. So when they become eligible for Medicare
because of end stage renal disease they are not in an obligation to enroll in Medicare.
If they have a marketplace plan, of course, they don’t have to enroll in Medicare and
they can keep that plan going. The third group of individuals are those who are not collecting
social security retirement benefits before they turn 65. As we all know retirement age
have gone up so many people are full retirement age is actually over 65. So many individuals
are postponing – applying for social security retirement benefits. If that’s their case
when they turn 65 they have an option to apply and enroll in Medicare even though they’re
not applying for social security retirement benefits yet. Now those individuals have the option not
to apply for Medicare altogether at the age of 65 and keep their marketplace plan going.
Keeping in mind that in either case when the individual becomes eligible to receive Medicare
Part A or free Medicare Part A their premium tax credit will be suspended. So although
they don’t have to enroll in Medicare they can keep their marketplace plan going. They
may lose the assistance that they get or the premium tax credit in the marketplace. We
always caution individuals who decide to delay enrollment in Medicare of the fact that they
may face a late enrollment penalty if they decide to enroll later on specifically for
Medicare Part B. Normally individuals or generally individuals
are qualified for free Medicare Part A. They can enroll anytime in the future and there
would be no penalty for Medicare Part A, but the Part B is the one that individuals are
not generally entitled for it and they may face the penalty if they tried to do it later.
They can only do so from January 1 to March 31 of each year and the coverage usually will
not begin until July 1 of that year. So that’s another thing that we wanted to highlight
and bring to your attention in turn so that the options whether or not to get Medicare
and to keep their marketplace going. Now let’s look at the slide number 8, which is the one
that address people with disability on Medicare. So I as I mentioned before individuals who
apply for Social Security benefits and are found eligible for those benefits usually
they will get those benefits after five months of waiting period and there after they receive
the tax benefit they have to wait 24 months before they become eligible for Medicare.
Now this happens automatically. So if an individual is over receiving social security disability
benefits, entitlement to Medicare will happen at the 24 month and they will be automatically
signed up for Medicare at that time. Those 24 months that they’re waiting to
enroll for Medicare entitlement, of course, they can access the marketplace and even apply
for premium tax credit, cost share reduction, but keeping in mind that once they hit the
24 month they will receive their Medicare card in the mail from social security which
have a Medicare Part A and Part B and at that time if they choose to keep that marketplace
plan although they become enrolled in Medicare if they were receiving any tax credit or cost
share in reduction they will lose that at that time. The 24 month – I just wanted mention real
quick that the 24 month doesn’t apply to everybody. For example, there is an exemption
or an exception for those who have Amyotrophic Lateral Sclerosis or the so called Lou Gehrig’s
disease. If an individual qualified for social security because of the Lou Gehrig disease
they don’t have to wait the 24 months. So what it means is that they will get Medicare
right away. Slide number 9 addresses those individuals who are working for a small employers
and those are smaller employer’s maybe purchasing health insurance through the small business
health option program. We just wanted to call to your attention that
this will not be – having a coverage through a small employer through the marketplace that
doesn’t really change the traditional rules with Medicare. Meaning that if you have an
employer group health plan through yourself or a spouse and that is based on current employment
that typical Medicare secondary payer rules apply and those individuals qualify for a
special enrollment period. That means that if you are currently working you don’t have
to enroll in Medicare Part B when you turn 65. You can enroll in Medicare Part B any
time the individual or spouse is working or if they lose that plan or they retire we give
them 8 months special enrollment period to sign up for Medicare Part B without having
to pay the premium penalty. So anyone who is getting health insurance
through a small employer, again, whether it is through the market place, small business
option or outside of the marketplace – this special enrollment period rules apply and
the traditional Medicare secondary payer rules apply to those employers. Slide number 10,
Medicare and prescription drug coverage. As I mentioned and also those individuals
seeking to enroll in the standalone dental plan through the marketplace. So with regards
to Medicare prescription drug coverage while the drug coverage in the essential – is an
essential health benefit in the marketplace a prescription drug coverage in the marketplace
or the small business plan isn’t required to be at least as good as Medicare Part B
coverage or what we call credible coverage. Meaning that if you have credible coverage
or credible prescription drug coverage you don’t really need to enroll in the Part
B plan. You can always do so later on and you will not be penalized. However all private
insurers offering prescription drug coverage including marketplace and the small business
plans are required to determine either prescription drug coverage is credible each year and let
the individuals know. So in other words there have been rules going all the way back to
2003 when the prescription drug benefits was put into law that requires anyone who offers
prescription drug benefits to individuals in Medicare to let them know whether that
plan is credible or compared to Medicare Part D plan. The marketplace plans don’t have to be credible,
however, they do need to tell an individual whether the coverage they’re offering is
compared to the Medicare Part D plan. So if you don’t enroll – if you don’t have a
credible coverage and you don’t enroll in Medicare Part D plan during initial enrollment
period you may have to pay a penalty. The penalty is usually 1% per month that you went
without the prescription drug coverage and you could have enrolled. Now with regards to a standalone dental plan
– in most cases you may not be able to purchase standalone dental plan through the marketplace.
If the marketplace in your state is run by a federal government you won’t be able to
buy a standalone dental plan through the marketplace unless you’re buying a health plan, however,
if your state is running their own marketplace you may be able to join a standalone prescription
drug plan. Slide number 11. So we have a couple of – kind of a typical
scenario that represents the majority of the questions that we’re getting from the marketplace
and the first case scenario we have is (Jim) who has Medicare Part A only, usually that’s
the typical approach – individual, because Part A is usually free. They think that Part
A and they decide to postpone enrollment in Medicare Part B. He did enroll in Medicare
Part B during his initial enrollment period. He signed up for Medicare Part B in January
2014 during the general enrollment period and his coverage began July 1. So the question
is can he enroll in the marketplace plan while he waits for his Medicare Part B coverage
to take effect. Go to the next slide, slide number 12, to answer that question. So the question – the answer is no. Medicare
Part A, as I mentioned before, is considered minimum essential coverage. He cannot get
a marketplace plan since he already – he’s enrolled in Medicare Part A and is a minimum
essential coverage and remember it is illegal for anyone to sell him a marketplace plan
knowing that he has Medicare. The next example, the next slide – slide number
13. So this is (Barbara) who works part-time and isn’t getting social security retirement
benefits yet. Remember that I mentioned that many people retirement age are beyond 65 and
this is an example. (Barbara) who is still working – here employer doesn’t offer health
insurance coverage so she enrolled in a marketplace plan. Her Medicare initial enrollment period
ends next month, but she decided to keep her marketplace plan and wait to sign up for Medicare. So she basically reached 65. She’s getting
a marketplace plan. She decided I’m not getting social security retirement benefits
yet. I’m just going to go ahead and keep my marketplace plan ongoing. So will (Barbara)
have a late enrollment period when she signs up for Medicare Part B? And what about Part
D? And what else should we tell (Barbara) to keep in mind as she makes her decision?
Next slide, slide number 14 has some answers. So (Barbara), in fact, can choose a marketplace
coverage if she’s eligible for Medicare, but hasn’t enrolled in it yet because, as
we mentioned before, she would have to pay premium for example and because she’s not
collecting social security benefits, which is her case. But before making her choice
there are two important things that she needs to keep in mind. If she enrolls in Medicare
after the initial enrollment period ends she may have to pay a late enrolment period as
long as she has Medicare as we mentioned before. Generally she can enroll in Medicare only
during the Medicare general enrollment period so in January 1 through March 31 and her coverage
will not begin until July 1 of that year. Next slide, number 15, just continues with
(Barbara). If the marketplace plan prescriptions drug
coverage credible she may also have to pay a late enrollment penalty for Medicare Part
D if she decides to enroll later on. SO (Barbara) we should tell Barbara that she should consider
enrolling in Medicare to be sure she doesn’t face a late enrollment penalty for Medicare
Part B or D. S can also choose to keep our marketplace coverage and also enroll in Medicare
as we mentioned before. In that case (Barbara) wouldn’t be eligible
for tax credit and there is no coordination of benefits between Medicare and the marketplace.
So in January – in general even though an individual is in the marketplace they get
Medicare, they have two different policies. Those marketplace plans are not designed to
supplement Medicare except in very limited circumstances. Next slide, number 16. Have some information – or perhaps a website
marketplace that’s cma.gov, which has a lot of information in there about Medicare
and the marketplace and other topics. You can keep on going to slide 17, which provides
several ways that an individual can go about accessing more information and slide 18 we’re
going to pause here a little bit as we finish that topic to see if anyone has any questions
so far with regards to Medicare and marketplace coverage. (Alicia Mcentire): Operator, can you open
– give instructions on how to ask a question? Coordinator: Thank you. At this time if you’d
like to ask a question please press star 1 on your touchtone phone. To withdraw your
question at any time please press star 2. One moment for our first question. Again,
if you’d like to ask a question please press star 1.I’m showing now questions at this
time. Oh, we do have one that just came in. Our first question is from (Beth Shaken).
Your line is now up. (Beth Shaken): Hi, yes, I wanted to just clarify
in terms of Medicare and then a marketplace plan. You had mentioned there’s no coordination
of benefits. So would that just be an instance of a person they have two separate insurance
plans that they would then choose who to submit a claim to? (David Santana): Great question. So if they
have Medicare – if they have a marketplace plan and then they become eligible for Medicare
and they choose to enroll in Medicare and keep that plan we’re talking about individual
health policies here. So we’re not talking about a small business. So if you have an
individual policy Medicare is your primary health insurance. By law Medicare is your
primary health insurance if you decide to keep that marketplace plan. So Medicare will pay and when we say there’s
no coordination of benefits it’s really no – an official agreement between Medicare
and those plans in the marketplace to coordinate benefits. Meaning that we would process the
claim, we’ve paid out claims and we make cross over those claims to those companies
so they can pay the rest. What we instruct the individuals to do in our situation is
they decide to keep those plans is to contact their plan and find out how exactly would
they work when you enroll in Medicare. They – the first thing they will tell you is that
Medicare will be your primary health insurance. They may tell the individual once Medicare
processes the claim you can always forward to us and we may help you with what’s left,
but again, it is important for individuals to contact their plan and ask them because
there’s an official coordination of benefits between Medicare and the plan and they may
as well say, you know, now you have Medicare that will be primary it’s up to you to keep
the plan. We may or may not pay after Medicare pays as a primary. (Beth Shaken): Thank you. (David Santana): You’re welcome. Coordinator: Your next question comes from
(Sandy Spies). Your line is now up. (Sandy Spies): Hi, thank you. I was wondering
if you have a client that is a vet and they get services from VA and then they come eligible
for Medicare. How does that work? (David Santana): If an individual who has
VA benefits and becomes eligible for Medicare, of course, they have the option if they’re
getting social security retirement benefits, as I mentioned before, when they turn 65 they
will get automatically enrolled in Medicare. They will receive the card in the mail and
they will have the option to keep Medicare Part B or decline Part B. If they are not
getting Social Security retirement benefits when they turn 65 then they are faced with
a choice. Should I enroll in Medicare during my initial enrollment period or should I postpone
enrollment in Medicare? If they decide to postpone enrollment in Medicare although they
have a VA coverage VA would not entitle that individual for a special enrollment period.
So what (unintelligible) is that individual will have to pay a penalty later on if they
decide to enroll in Medicare. Coordinator: Our next question comes from
(Kim Glawn). Your line is now open. (Kim Glawn): Hi, I think you had mentioned
that some people who age into Medicare may, with a marketplace plan, that they might end
up delaying Part B coverage or Medicare coverage in general and that there were problems they
could encounter with enrollment periods and penalties but that for people with premium
free Part A or without – that certain individuals like people with – who don’t qualify for
premium free Part A, some of those individuals might be – well, in the best position not
to have to choose to go into Medicare and drop their qualified health insurance plan. We were wondering – this goes back to coordination
of benefits, but if a person chooses to stay in their qualified health plan and not enroll
in Medicare could the qualified health plan say have a clause in their policy that dictates
that the plan doesn’t have to pay for benefits as primary if the person failed to enroll
in Medicare? So meaning like would the person think that they have qualified health insurance,
you know, through the marketplace thinking that they were okay, but then later find out
that there’s a clause that would allow insure not to pay as primary. (David Santana): Yes, that is a great question.
Traditionally individuals who are enrolled in private health – individual private policies
or enrolled in a small group health insurance plan, meaning less than 20 employees, those
plans always have the right – only the coordination of benefits laws to tell an individual now
that you are qualified for Medicare you must enroll otherwise we only help you pay for
what Medicare would have left. Meaning that we will pay like Medicare was there all along.
And that law expires – as far as I know the law hasn’t changed with regards to the Affordable
Care Act. The Act does tell those plans that they have
to be guaranteed renewable. Meaning that they couldn’t terminate the policy just because
a person is becoming eligible for Medicare, however, the coordination of benefits rules
that exist before the Affordable Care Act do allow those plans either small group health
plans less than 20 employees and those individual policies to put (unintelligible) in place
saying you must enroll in Medicare otherwise we’re just going to pay what Medicare would
have left behind. And that’s a great question. (Kim Glawn): Thank you. Coordinator: There are no more questions in
queue at this time. (David Santana): Great, thank you so much.
And so we’re going to go on and jump through the slides, number 18. And during this part
of the presentation we will focus Medicare and mental health services. Specifically what
Medicare coverage for those individuals who are suffering from mental health condition.
So mental health conditions like depression or anxiety can happen to anyone at any time
and can affect a person of any age, race, religion or income for that matter. However,
mental health illness, as we all know, are treatable. So the following on that slide
are signs that an individual may want to speak to a doctor or mental health professional
if they’re experiencing any of those symptoms. We’re going to go on to slide number 20. Diving into specifically what an individual
will get under Medicare Part A with regards to mental health services. So Medicare Part
A, which is a hospital insurance and we’ve talked a little bit about it already helps
pay for mental health care if you are an inpatient in a general or psychiatric hospital. Once
the individual is in the hospital – and this applies pretty much for everyone not specifically
to mental condition, but we will say, for example, room and board, meals, general nursing
care, prescription drug and oral related services and supplies. Pretty much all the services
that an individual will get as an inpatient hospital. Now the last bullet in there is kind of like
the unique treatment of those individuals who are in the hospital to treat psychiatric
conditions. So there is a lifetime maximum of 190 days on inpatient psychiatric hospital
services allowable to any beneficiary enrolled in Medicare. Therefore, once the individual
receive benefits for 190 days of care in a psychiatric hospital no further benefits of
that type are allowable under the Medicare program for that individual. Payment may not
be made for more than 100 or a total of 190 days of inpatient psychiatric hospital services
during the patient’s lifetime. Again, this is a lifetime benefit. This limitation applies
only to services, for instance, in a psychiatric hospital. So, again, it only applies to service that
an individual will receive in a psychiatric hospital. This limitations do not apply to
inpatient psychiatric service (unintelligible) in a distant part psychiatric unit of an acu-care
hospital or critical access hospital. So, again, let me repeat that because I know we
get a lot of these questions. The limitation does not apply to inpatient psychiatric services.
For instance in a distance part of the psychiatric unit of an acute care hospital or in a critical
access hospital. The period they spend in a psychiatric hospital prior to entitlement
does not count towards this limitation. Although this (unintelligible) appear that an individual
spends in a psychiatric hospital before they become entitled for Medicare may be counted
in terms of a limit for the first initial coverage period in Medicare and the next slide
I‘m going to talk a little bit about that. I’m going to go on and move to slide 21. So slide 21 shows the way we actually reimburse
on the Medicare Part A services. So we reimburse Medicare Part A services based on benefits
period. To understand these numbers we have to first understand what a benefit period
is. So a benefits period begins when an individual on Medicare becomes an inpatient in a hospital.
So that’s when they – benefits (unintelligible) begins and that period will end when the individual
has been out of the hospital or skilled nursing facility for two months or 60 days. So every time an individual goes into the
hospital to spend a certain amount of time and they get out of the hospital for two months.
That benefit period will recycle again and there is no limits in a benefits period. That’s
an individual and Medicare (unintelligible). You can see on each benefit period, for example,
from one day up to 60 days in the hospital the individual in 2015 is responsible to pay
a deductible and Medicare pays the rest. From day 61 to day 90 if the individual remains
in the hospital for that long then the individual would be responsible to pay a co-payment of
$315 a day Medicare pays the rest. Now once a person hits that 90 days consecutive
days in the hospital or in a benefits period that individual will follow what we call 60
lifetime reserve days. So they do have 60 days lifetime reserve that they can use after
they use – after – in a benefits period they have used that 90 days. And, as you can see,
they have to pay half of the deductible per day if they decide to use those 60 days lifetime
reserve days. Now once they use it they’re gone. So if the individual used those 60 days
lifetime and they come back to the hospital they have to be aware that Medicare benefits
will go up to a 90 days in the hospital and there after Medicare coverage for hospital
care at that point will end. Now something that is distinct with reference to individuals
who are – or who have some Medical condition that they were receiving care in a psychiatric
hospital. So when an individual becomes eligible for
Medicare for the first time if they are an in-patient and participate in Psychiatric
hospitals on that first date of entitlement to hospital insurance the number of inpatient
benefits, you know, in a first benefits period is the subject to reduction. So, again, we’re
looking at 150 days and we’re saying that if that individual was an inpatient in a psychiatric
hospital while they became entitled to Medicare that 150 days will be reduced. So that days, not necessarily consecutive,
in which the individual was an inpatient of a psychiatric hospital in the 150 days period
immediately before the first date of entitlement must be subtracted from the 150 days of the
inpatient hospital service for which it would be eligible to look at. To further explain
this a little bit, because I know this is kind of – it’s a lite tricky rule that only
applies to those individuals who are inpatient in a psychiatric hospital. The first date
that they become entitled for Medicare. So, for example, I just gave you an example.
A person was admitted into a Medicare participating psychiatric hospital. Let’s say in January
20. The person entitled for Medicare began February 1, but you can see there were 12
days in there. So the 12 days of inpatient psychiatric care prior to entitlement are
deducted from the 150 days available for that first benefit’s period. So that tells us
that that individual have 130 days left in that benefit’s period. So what that means is if an individual’s
remains in hospital for that 130 days at that point Medicare coverage will stop and when
an individual has been out of the hospital for 60 days in a row then they will begin
a new benefits period from that point forward. So I hope that this part that only applies
to those individuals who were inpatient in a psychiatric hospital when they become eligible
for Medicare is understood and that’s because you probably may get questions from individuals.
I became eligible for Medicare and they’re only paying for this much hospital care from
this point forward because they are talking about some reduction on that benefits period
because I was an inpatient in a psychiatric hospital. I’ll be happy to talk a little
bit more if anyone has questions about that. Let’s move on to slide number 22. Now let’s take quick look at Medicare Part
B services. So Part B help cover for mental health services provided by doctors and other
health care professionals if you are admitted as hospital inpatient – also covers outpatient
mental health services that the individually generally gets as a hospital outpatient or
outpatient hospital. Including visits – visits with those types of health care professionals
such as Psychiatrists or other doctors, clinical psychologists, critical social workers and
certain other health care professionals. Let’s move on to slide number 23. So part B also helps pay for those coverage,
for example, one depress screening every year and this – we will cover for one depression
screening every 12 months. So although the individual is entitled to this benefit we
caution individuals that they cannot go unless 11 full months have lapsed for Medicare to
cover for the services. If they go more frequent than that we would likely deny the claim.
And so we started this coverage back in October 2011 and basically we will cover annual screening
up to 50 minutes for Medicare beneficiary in primary care settings that have established
this for depression care support in place to assure accurate diagnosis, effective treatment
and follow up care. So various screening tools are available for
screening for depression and I wanted to call to your attention a question that we often
times get is that (unintelligible) does not identify specifically a depression screening
tools. So rather the decision to use the specific tool is at the discretion of the clinician
in the primary care setting and as I mentioned before a screening for depression is not covered
when it’s performed more than 1 time in the twelve-month period. Another thing that I wanted to call to your
attention is that Medicare co-insurance and Medicare Part B deductible are weighed for
these specific preventive services that we are mentioning here on this slide. So there
are many individuals on group therapy, family counseling, psychiatric evaluation, medication
management and certain prescription drugs and injections. The last bullet in there speaks to in some
cases a Medicare Part B may also pay for partial hospitalization, which is an intensive structure
program of outpatient psychiatric service provided to patients that – as an alternative
brief patient psychiatric care. So to explain this a little further – so patients admitted
to this program must be under the care of a physician who certifies the need for partial
hospitalization and requires a minimum of 20 hours per week therapeutic services as
well as evidenced by their plan of care. he patient also requires comprehensive instructional
treatment requirements, medical supervision and coordination provided under the individualized
plan of care because of a mental disorder, which barely interferes with multiple areas
of daily living, including social locational and educational (unintelligible). So generally
patients meeting the meeting the benefits category for this specific coverage are two
groups of patients. Those patient who are discharged from an inpatient hospital treatment
program and this intervention – this same deal continues in patient treatment or (unintelligible)
in the absence of partial hospitalization would be reasonably at risk of requiring inpatient
hospitalization. So, again, I wanted to highlight that last
bullet and imply that we also get many questions about the partial hospitalization coverage
under Medicare. Let’s move on to slide 2, which talks a little bit about how much the
individual paid for Medicare Part B. usually for mental health services provided by doctors
or other health care professionals the individual user usually pays – Medicare paid 80%, the
individual paid usually 20%. We wanted to call to your attention that if an individual
gets services in a hospital outpatient clinic or hospital operation department they may
have to pay an additional co-payment of co-insurance. That additional co-payment co-insurance may
range between 20% and 40% and this is, again, if they received the service in an outpatient
clinic or hospital outpatient department. Slide 25 talks about what’s covered under
Medicare prescription drug plans. So the Part D plan helps cover for drugs that may need
to treat mental health conditions and this slide specifically addresses what we call
required coverage or protective categories of drugs that are covered by each of every
plan that offer prescription drug benefits. Those protected categories are usually five
of them. The first one is cancer medication, HIV-Aids
treatment anti-depressant, anti-psychotic, anti-convulsion and also immune suppressant
drugs. So those are three categories in there in which relate specifically to mental health
conditions are required to recover by each and every Medicare Part D plan. Slide number
26 in terms of how much individual usually pay for Part D plans. Of course, these plans
are private plans and they may – the price may vary. It depends on the plan that you
enroll in the coverage. Those individuals who have limited income
and resources could qualify for assistance for their premium as well as the out of pocket
expenses. Slide 27 and 28 and actually 29. They’re just more informational resources
there that you can go through the information with regards to coverage for mental health
services. And that concludes my very quick over view
about Medicare coverage for mental health services. And I would be more than happy to
take questions if you have any question about that specific topic. Coordinator: Again, if you’d’ like to
ask a question please press star 1 on your touchtone phone. To withdrawal your question
at any time please press star 2. One moment for our first question. Again, if you’d
like to ask a question please press star 1. I’m not showing any questions in queue at
this time. (Alicia Mcentire): (David) this is (Alicia
Mcentire) and while we’re possibly waiting for any further audience questions I just
was wondering what you think is maybe one of the kind of biggest barriers to enrolling
– enrollment and how we might be able to further engage and reach, you know this eligible population
that we’ve talked about today. (David Santana): With regard to Medicare population
I mean there are many venues already in place I mean the program has been around since 1965
so there’s certainly a broad range of groups and agencies and advocacy organization that
helped those individuals navigate through their options. Specifically I will refer if
anyone wanted to assist those individuals specifically when it comes to choosing, for
example, should I – mean I am becoming eligible for Medicare what are my options? Did I enroll
in the Medicare Advantage plan? Should I get a supplemental plan. Should I get a Part B
plan? We have the senior health insurance programs
that are spread throughout the nation and we have individuals in each and every county
in the US that provides one on one counseling to individuals in Medicare. To sit with them
and help them navigate through their options. I don’t have their specific phone number
listed in there, but the individual could always, you know, call 1800-medicare and ask
for the shift program. Senior Health Insurance Recipient program in their state and they
would be able to get, again, one on one personalized assistance to help them with their options. One of the things that individuals usually
ask specifically to this small group that I was addressing that have the option to,
you know, reject Medicare and keep the marketplace plan and premium tax credit. We tell individual
not to jump into conclusion and just because they have that option that may be the best
option for them. Because the program has been around for too long there are options for
those individuals who cannot afford Medicare premium. We call Medicare Savings Programs and those
plans are allowable in each and every state in the nation and those programs may help
for Medicare Part D premium, Medicare Part A premium and also out of pocket expenses.
Does the individual have a comprehensive health insurance. They don’t have to pay anything
out of pocket. So I encourage them before jumping to a conclusion and say oh this is
the best I can to evaluate their options. (Alicia Mcentire): Thank you. (David Santana): Thank you. Coordinator: There are no questions in queue
at this time. (Alicia Mcentire): All right, well we are
at the end of the hour. So if there are no questions I would like to, again, thank (David
Santana) from CMS and thank everyone for their participation today. This concludes the webinar,
thank you. Coordinator: This does conclude today’s
conference. All participants may disconnect at this time.

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