Medicare Advantage, mental health and substance use disorders

In our last post, we looked at how recent policy changes  impacted the treatment of mental health and substance use disorders for beneficiaries on Original Medicare. What differences exist for the nearly half of beneficiaries on Medicare Advantage plans? Let’s dig in.

Cost-sharing for mental health and substance use disorder services
First things first: Medicare Advantage plans must cover all Part A and Part B services, so everything we discussed last time (annual visits, screenings and treatments) will be covered. What changes with each and every plan, though, is the cost-sharing requirements.

For example, a Medicare Advantage plan might require daily copayments for inpatient hospital stays starting on day one, while Original Medicare will subject beneficiaries to a deductible without copayments for the first 60 days of a stay. Costs for outpatient services will also vary: Medicare Advantage plans will generally require a flat copay for physician’s services. Original Medicare will require that beneficiaries first satisfy a deductible, and then pay 20% coinsurance for each visit.

Accessing care
Since Medicare Advantage plans are run by private insurance companies, each plan contracts with doctors and mental health providers to form its network. Beneficiaries enrolling in a Medicare Advantage plan are generally limited to their plan’s unique network; conversely, those in Original Medicare are free to see any provider who accepts Medicare’s payment schedule as the full fee for services rendered.

However, each Medicare Advantage plan must meet network adequacy standards. These standards ensure that each plan has an adequate number of providers across a number of specialties – including mental health – in its service area.

We should also note that Medicare Advantage plans may require referrals and/or prior authorizations for Part A and Part B services. In particular, 94% of enrollees are in a plan that requires a prior authorization for an inpatient psychiatric hospital stay, 85% are in plans requiring prior authorization for opioid treatment programs, and 85% are in plans that require an authorization to see a mental health provider. These measures are meant to ensure that the use of each service is appropriate, but they may present barriers to individuals who need immediate care.

Engaging with telehealth
Medicare Advantage plans are not bound by the same geographic restrictions as Original Medicare. Enrollees may take advantage of these services from the comfort of their own homes and are unlikely to face in-person requirements – unless their individual plan requires it. 98% of all Medicare Advantage enrollees have a telehealth benefit embedded in their plans.

Final thoughts
Although Medicare Advantage plans cover the same benefits as Original Medicare, there are significant differences in how these payors facilitate access to care. Savvy agents and brokers do well to explain these differences when helping beneficiaries find the right benefit package to fit their needs.