What to know about Medicare and mental health care

About 15% of people over the age of 60 experience depression or anxiety disorders, which can damage quality of life and even shorten lifespan because of substance abuse or other unhealthy behaviors.

The reasons are varied: isolation, loss of a spouse, health conditions, cognitive decline. If you’re experiencing a mental health challenge, you may be wondering how Medicare covers treatment and medications.

Learning what mental health services are covered by “original Medicare” is as simple as going to medicare.gov and searching “mental health.” If you have a Medicare Advantage plan, search with your insurance company. Medicare Part B covers, among other things, psychiatrists, clinical psychologists and licensed clinical social workers, along with inpatient treatment and community mental health centers.

Finding providers and facilities that accept Medicare assignment, however, isn’t as easy. Studies have found that people seeking mental health care carry a significant “cash burden,” as about half of psychologists and psychiatrists in private practice don’t participate in insurance plans.

To find a provider, search medicare.gov or your Medicare Advantage website. Two other good resources are PsychologyToday.com and GoodTherapy.org, where you can find providers and facilities searchable by location, treatment specialties and insurance coverage.

It’s sometimes hard to get an appointment, though, which is why people are increasingly turning to online providers, such as BetterHelp.com and Talkspace, some of whom accept insurance. Out-of-pocket costs, however, may be lower with these providers.

Before getting therapy, call your insurance provider and ask specific questions: Do I have residential coverage? Do I have intensive outpatient or partial hospitalization coverage? Are there in-network facilities out-of-state? What is my out-of-pocket maximum?

Help navigating treatment choices is available from most insurance companies in the form of ombudsmen and advocates; call the customer service number on the back of your insurance card to get connected. Medicare also has a Medicare Benefit Ombudsman as well, but it’s recommended that patients or families first contact their provider.

A good advocate will try to get you coverage for facilities and providers that may be out-of-network but provide what you or a loved one needs for treatment. Be aware, though, that some plans restrict you to getting care to where you live or in surrounding states.

Very often, I’m contacted by a family with a loved one in crisis, who may need to go directly to an emergency room and receive inpatient treatment so they don’t harm themselves or others.

Usually, when the patient is deemed stable and responding well to medication, they are released and instructed to continue therapy as an outpatient or in a community-based program. A three-day hospital stay will make you eligible for up to 100 days of rehab under Medicare, but you have be progressing in recovery. You may also need to be placed in a facility that accepts psychiatric patients. Many do not.

Speaking of medications, drugs play a big role in managing mental illness, and new ones are being approved by the Federal Drug Administration (FDA) all the time. For example, just last year, the FDA approved Cobenfy (xanomeline and trospium chloride) for the treatment of schizophrenia in adults. (As a reminder: Only a psychiatrist, who is a medical doctor, should prescribe treatments for a mental disorder.)

However, many of those new drugs come with hefty copays under Medicare Part D and Medicare Advantage drug formularies, or aren’t covered at all. If a new medication isn’t affordable, a doctor may prescribe an older version or generic that isn’t as effective. Fortunately, starting this year, out-of-pocket drug costs are capped at $2,000 for Medicare recipients.

According to the Centers for Disease Control and Prevention, mental health disorders in older adults are often underdiagnosed and undertreated. Just because you’ve been able to power through emotional ups and downs your whole life, don’t ignore symptoms of depression and anxiety that don’t go away. These may include:

● Staying in bed all day because of listlessness and fatigue.

● Inability to enjoy the things you used to enjoy, whether that’s a hobby or a physical activity.

● Not caring if you see or speak to family members or friends.

● Increasing reliance on alcohol or medications to manage mood.

Recognizing symptoms and getting therapy early, before a minor mental health challenge blossoms into something more, will keep you healthier — and may even prolong your life.

• Bonnie Lane, M.S., is principal consultant with Family Support Services in Northbrook, specializing in supporting families whose loved ones suffer from severe mental illness or substance addiction. Daily Herald readers can contact her at (847) 651-1554 or bonnielane@thefamilysupportservices.com.