Monday, July 26, 2010

Ask the Expert: Why doesn’t Medicare have to follow the Mental Health Parity Act?

Q.  Why doesn’t Medicare have to follow the Mental Health Parity Act, which mandates that insurance plans cover both physical and mental ailments equally, including maximum limits on hospital stays? 
mileena, California

Medicare will cover office- and clinic-based therapy as well as services you receive in an outpatient hospital program, as long as your provider is one of the following:
• a general practitioner
• a nurse practitioner
• a physicians’ assistant
• a psychiatrist
• a clinical psychologist
• a clinical social worker
• a clinical nurse specialist

Medicare will help pay for the services of non-medical doctors (like psychologists and clinical social workers) only if the providers are Medicare-certified and take assignment, meaning that they accept Medicare’s approved amount as payment in full.

For your initial visit to a mental health professional to determine your diagnosis, and for brief appointments to manage your medications, Medicare pays 80 percent of its approved amount. For other appointments after your initial visit, Medicare pays 55 percent of its approved amount. You or your supplemental insurer are responsible for the remainder of the bill (20 percent or 45 percent coinsurance, respectively).

These are among the mental health services Medicare covers:
• Individual and group therapy.
• Family counseling to help with your treatment.
• Tests to make sure you are getting the right care.
• Activity therapies, like art, dance or music therapy.
• Occupational therapy.
• Training and education (like training on how to inject a needed medication or education about your condition).
• Substance abuse treatment.
• Laboratory tests.
• Prescription drugs that you cannot administer yourself, like injections that a doctor must give you.

You are correct that the Mental Health Parity and Addiction Equity Act of 2008 prohibits insurers from charging more for mental services than other services, but the law applies only to employment-based insurance plans. Thus, Medicare is not affected. But under the Medicare Improvement for Patients and Providers Act of 2008, Medicare coinsurance for mental health services will be gradually reduced over the next five years. This year and next year, consumers will pay 45 percent for most mental health services, in 2012, they will pay 40 percent, in 2013 they will pay 35 percent and by 2014, consumers will pay 20 percent — just as they do for most other services.

The Medicare improvement law will not change how Medicare covers inpatient mental health services. If you receive care in a psychiatric hospital, Medicare helps pay for up to 190 days of inpatient care in your lifetime. After you have reached that limit, Medicare may help pay for mental health care at a general hospital. Your out-of-pocket costs are the same in a psychiatric hospital as they are in any hospital. In February, Senators John Kerry and Olympia Snowe introduced the Medicare Mental Health Inpatient Equity Act, which would eliminate the 190-day limit on inpatient psychiatric hospital stays and cover inpatient psychiatric hospital stays much as it does all other hospital stays under Medicare. Congress has yet to take action on this legislation.

Thursday, July 1, 2010

NEDA: New Health Care Coverage for Pre-Existing Conditions! (Sadly not in NJ)

The U.S. Department of Health and Human Services (HHS) announced on July 1st the establishment of a new Pre-existing Condition Insurance Plan (PCIP) that will offer coverage to uninsured Americans who have been unable to obtain health coverage because of a pre-existing health condition.

States have the opportunity to develop their own plan for assuming this coverage, and have until 2014 to do so, or they can opt to have HHS oversee this on their behalf. Altogether, 21 states have turned implementation over to HHS; the national Pre-Existing Condition Insurance Plan is now open to applicants in these 21 states where HHS is operating the program.

Click here to see if your state is one of the 21 states where coverage is now available.

PLEASE NOTE THAT NEW JERSEY IS NOT ON THE EARLY IMPLIMENTATION LIST!  The national Pre-Existing Condition Insurance Plan will launch in NJ in 2014. 

To find out more information, or to enroll in coverage, you can visit:

HuffPo: Understanding 'Non-Specified Eating Disorders'

Imagine that your doctor told you that you suffered from a disorder that was "not otherwise specified." How would you feel about the seriousness of your condition? Would you feel nervous? Or maybe you would dismiss it as unimportant? These are the questions that confront nearly 70 percent of patients with eating disorders. We have all heard of anorexia and bulimia, but what you may not know is that there is a class of eating disorders called Eating Disorder Not Otherwise Specified (EDNOS).

EDNOS causes more deaths than either anorexia or bulimia (1). Currently, patients are diagnosed with EDNOS if they fail to meet all the requirements for anorexia and bulimia. However, the newest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a cornerstone of psychiatry, plans to address this vagueness so that current EDNOS patients will no longer struggle with that uncertainty.

In our image-obsessed society -- where fashion models are fired for not being skinny enough and a clothing company can cause uproar by featuring the slogan "Eat Less" on a t-shirt -- eating disorders are a dangerous reality. More Americans suffer from eating disorders than Alzheimer's disease and schizophrenia combined (2). In addition, more than a third of normal dieters develop an eating disorder (3).

Eating disorders often point to more serious underlying mental illnesses, like body image issues or depression. Disrupted eating patterns are the common sign, but there are other signs that suggest that someone is suffering from an eating disorder. These include never wanting to eat, uncontrollable eating tied to emotional states, repeatedly chewing and spitting out food without swallowing, frequently using laxatives or enemas, and self-evaluation heavily dependent on body image (4).

To address the high number of EDNOS cases, DSM-5 (the latest version of the manual) will better specify illnesses like Binge Eating Disorder, for example. This is useful because many disorders that are grouped together under EDNOS are not very similar; they have different characteristics and require separate attention and treatment. By doing this, both doctors and patients have a clearer understanding of which eating behaviors need to be treated, instead of shrugging it off as "unspecified."

If you were a patient, wouldn't you feel more positive about the outcome of your disease knowing that it is more than just "non-anorexia" or "non-bulimia?" Also, doctors will be able to choose more suitable strategies for how to treat these behaviors.

This change is not without controversy, though, as some doctors think that "over-specifying" these disorders in DSM-5 means patients will be diagnosed with disorders that they don't truly have (5). Will this really happen? We don't know, but I believe it will allow for eating disorders in patients to be identified more clearly and treated more effectively.

Eating disorders are a serious medical condition. If you notice these signs in yourself or someone you know, get help. Speak with a doctor about counseling. Join a local support group or one on the internet. Educate yourself on the signs of eating disorders and learn how to prevent them.

As updates to the DSM show, these disorders are legitimate mental illnesses and they require treatment; they don't just go away on their own. The medical community is doing its part to deal with unspecified eating disorders by revising its guidelines, and we each need to do our parts by educating ourselves and intervening when we suspect eating disorders in friends or loved ones.