2018 marks the 53rd anniversary of the Medicare program. While Congress and the U.S. Centers for Medicare and Medicaid Services, the federal agency that runs Medicare, continue to refine the program, the basic structure of the program has remained in place since 1965.
How is Medicare serving people living with mental health conditions?
Medicare is more than a “health program for older adults.” Few Americans know that more than 10 million non- elderly people with disabilities are served by the program. People become eligible for Medicare two years after receiving Social Security Disability Insurance (SSDI). As many as one in four people are eligible for SSDI because of their mental illness.
How is the program meeting their needs?
Medicare provides important health coverage for people with mental illness, but also has significant gaps and inequities that compromise care for people with mental illness.
•When Congress passed the landmark Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008 — a law requiring health plans to cover mental illness and substance use treatment on the same terms and conditions as other health care — it did not apply the law to Medicare. Medicare remains the only major health plan in America that is not required to cover mental illness the same as diabetes and heart disease.
•Medicare imposes a limit of 190 days for inpatient psychiatric care in a person’s lifetime, but it does not have the same limit for other hospitalizations. Because mental illness typically strikes when people are young, it is common for Medicare enrollees with mental illness, such as schizophrenia, to reach this limit and no longer have coverage for inpatient care.
•With few exceptions, Medicare does not cover many of the long-term supports and services that people living with mental illness need, such as peer supports and Assertive Community Treatment (ACT), an intensive, team-based intervention that helps people with mental illness who are at high risk of hospitalization.
There is, however, good news.
•Since 2006, Medicare beneficiaries have had access to prescription drugs through the Medicare Part D program. Monthly premiums for the Part D program have been stable over the past decade and consumer satisfaction remains high.
•The Medicare Part D program has subsidies for people with very low incomes or who are eligible for both Medicare and Medicaid — many of whom live with mental illness — that allow for $0 monthly premiums and affordable cost-sharing at the pharmacy counter.
•Prescription Drug Plans (PDPs) in the Part D program are required to include “all or substantially all” antipsychotics and antidepressants approved by the Food and Drug Administration to treat mental illness on their lists of covered drugs, or formularies.
In addition, the Affordable Care Act (ACA) expanded the Medicare prescription drug benefit to eventually close the “donut hole” gap in coverage. The ACA also expanded coverage to include important preventive services in Medicare, such as diabetes screening, that are particularly vital for people with mental illness.
Finally, in recent years, the market of Medicare Advantage (MA) plans has resulted in many plans that offer better coverage of treatment for mental illness than the Medicare Fee-For-Service (FFS) program — plus the advantage of provider networks that help people find mental health professionals. Importantly, many MA plans do cover mental illness and substance use treatment at a level equivalent to treatment for other health conditions.
For over 50 years, Medicare has helped protect the health and well-being of millions of American families. But aligning Medicare with the needs of beneficiaries living with mental illness is long overdue. Congress should address discriminatory limits on inpatient psychiatric care, require equivalent coverage of mental health and substance use conditions and cover effective services, while maintaining existing protections in the Medicare Part D and Medicare Advantage programs that are helping people with mental illness access the care they need.
• Andrew Sperling is Director of Legislative and Policy Advocacy at the National Alliance on Mental Illness. Learn more at NAMI.org and @NAMICommunicate.
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