Dear Marci,
I receive outpatient mental health treatment for substance abuse. How much will Medicare pay for my treatment?
Giles
Dear Giles,
Medicare will help pay for treatment of alcoholism and drug abuse in outpatient settings if:
•You receive services from a provider or facility that accepts Medicare;
•Your doctor states that the services are medically necessary; and
•Your doctor sets up your plan of treatment.
Medicare Part B helps pay for outpatient substance abuse treatment services from a clinic or hospital outpatient department.
In 2012, Medicare will pay 60 percent of its approved amount for mental health services, and you or your supplemental insurance will be responsible for the remaining 40 percent.
You or your supplemental insurance will also be responsible for a coinsurance to the clinic or hospital, which can be no more than the inpatient hospital deductible for that year ($1,156 in 2012).
Covered services include, but are not limited to:
•Psychotherapy
•Patient education regarding diagnosis and treatment
•Post-hospitalization follow-up
•Prescription drugs administered during a hospital stay or injected at a doctor’s office.
Marci
Dear Marci,
I enrolled in a new drug plan during Fall Open Enrollment. When I went to the pharmacy in January to pick up my prescrition, there was no problem. But when I went to pick up that same prescription this month, I was denied and told that my plan doesn’t cover the drug. Why was the drug approved in January but denied in February?
Daphne
Dear Daphne,
Your drug was covered in January because you were eligible for a transition refill. A transition refill, also known as a transition fill, is typically a one-time, 30-day supply of a drug that Medicare drug plans must cover when you are in a new plan or when your existing plan changes its coverage.
A transition fill lets you get temporary coverage for drugs that aren’t on your plan’s formulary or that have restrictions on them (such as prior authorization or step therapy).
Transition fills aren’t for new prescriptions. You can only get a transition fill for a drug you were already taking before switching plans or before your existing plan changed its coverage.
All Medicare Part D drug plans must cover transition fills. The rules apply to both Medicare Advantage plans that include drug coverage and Medicare stand-alone drug plans. When you use your transition fill, your plan must send you a written notice within three business days. The notice will tell you that the supply was temporary and that you should either change to a covered drug or file a request with the Part D plan (called an exception request) to ask for coverage.
Marci
