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Issue_Spotlights

Medicare

 MEDICARE COVERAGE OF MENTAL ILLNESS TREATMENT

  • NAMI strongly supports congressional efforts to modernize coverage of mental illness treatment under the Medicare program – specifically to address the discriminatory aspects of programs such as the 50 percent co-payment requirement for outpatient mental illness treatment and a 190 day lifetime limit on inpatient hospitalization. NAMI supports the following bills in Congress to address these other inequities in Medicare: HR 599, S 841, S 690 and HR 1522,
  • NAMI strongly supports bipartisan efforts in Congress to add a prescription drug benefit to the Medicare program that provides adequate protections against the high cost of medications, ensures eligibility for both senior citizens and non-elderly people with disabilities on SSDI and does not administer benefits through use of restrictive formularies.

Parity Under Medicare

Medicare coverage of mental illness treatment has remained virtually unchanged since the program’s inception in 1965. This coverage continues to impose stigma-based distinctions in coverage between mental illness and other medical treatment. Medicare beneficiaries must pay 50 percent of the cost of outpatient mental illness treatment, as opposed to 20 percent for all other outpatient services. Similarly, Medicare imposes a 190-day lifetime limit on inpatient psychiatric hospitalization that is not imposed on all other inpatient treatment.

NAMI strongly supports various bills now before Congress to address these historic inequities in the Medicare program. Among these are HR 599 (Roukema), S 841 (Snowe/Kerry), S 690 (Wellstone) and HR 1522 (Stark) and urges the Bush Administration and Congress to incorporate them into efforts to enact comprehensive restructuring of the program.

Outpatient Prescription Drug Coverage Needed

Both President Bush and congressional leaders have pledged to make coverage of outpatient prescription drugs part of the Medicare program. This issue has been commonly framed as "coverage of prescription-drug benefits for seniors." Much to NAMI’s regret, few elected officials have discussed this popular issue in terms of providing such coverage for the 1.3 million non-elderly people with disabilities who are eligible for Medicare by virtue of having been on Social Security Disability Insurance (SSDI) for a minimum of two years.

Later this year, Congress is expected to take up several competing measures to add a prescription drug benefit to Medicare. All of these competing plans agree on the need for any Medicare drug benefit to be universal (all Medicare beneficiaries would be eligible for the benefit) and an entitlement. Further, all of the competing plans include some type of "stop loss" coverage – establishing a threshold above which all costs are covered (ranging from as low as $3,500, up to $7,000 in competing bills).

The separate House and Senate bills vary widely on several critical issues: a) costs and b) whether the program should be administered within the existing structure of the Medicare program (generally favored by Democrats) or through private sector plans (generally favored by President Bush and Republicans). On the issue of costs, proposals vary from as low as $200 billion over 10 years, up to more than $750 billion over 10 years. Because of the looming retirement of the large baby-boom generation, putting off enactment of a drug benefit raises the eventual costs by as much as 18% a year.

On the issue of program structure and delivery, a leading proposal authored by Senate Democratic leaders would add a new Part D to Medicare would administer a new prescription drug benefit through the existing Medicare structure. By contrast, a proposal being pushed by House Republican leaders would direct insurance companies and HMOs to offer prescription-drug coverage. This new benefit would be enacted in conjunction with larger, systemic reform of the entire Medicare program. Under this legislation, the government would not directly provide drug coverage, purchase drugs, or regulate prices. Instead, private health plans would be expected to offer a variety of options that would include drug coverage integrated into Medicare as well as "drug only" coverage added to the traditional Medicare program. These private plans would be expected to pass discounts to beneficiaries based on a federal subsidy for the premium costs for drug coverage. Other proposals would rely on Pharmacy Benefit Management (PBM) providers to administer a new drug benefit and penalize manufacturers that refuse to discount drug prices.

On the issue of restrictive prescription-drug formularies, most of the competing congressional proposals attempt to respond to Medicare-enrollee frustrations about access to the newest and most effective medications. Most proposals would bar the establishment of a uniform national formulary for any class of FDA-approved drugs. At the same time, each proposal either explicitly or implicitly assumes that insurers will be able establish their own formularies and each will have a process to allow beneficiaries to appeal decisions to deny non-formulary drugs.

As part of the debate over Medicare prescription drug coverage, NAMI supports the following principles:

  • prescription drug coverage must address the underlying discrimination in Medicare’s existing, overall mental illness benefit,
  • the 1.3 million non-elderly persons receiving SSDI benefits (25 percent of whom are eligible for SSDI because of a mental illness) must be eligible on the same terms and conditions as elderly beneficiaries),
  • coverage should be a standardized with entitlement for all eligible Medicare recipients,
  • coverage must be sufficient enough to pay for the most expensive drugs for the treatment of severe and persistent mental illnesses and include "stop loss" coverage, and
  • prescription drug formulary policies must adhere to a principle of open access to the newest and most effective medications for serious brain disorders such as schizophrenia, bipolar disorder and major depression.

 

 

 

 

 

 

 


Top Story

NAMI Statement on MEDPAC

What the Debt Limit Agreement Means for People Living With Serious Mental Illness
Learn about the provisions the debt limit agreement before Congress and how funding changes affect people living with serious mental illness.


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Understanding the Issue:

NAMI Statement on MEDPAC
2/09/2012

NAMI Comments on the Medicare Mental Health Inpatient Equity Act (HR 6143)
9/23/2010
Read submitted comments submitted by NAMI to Representative Paul Tonko in support of the Medicare Mental Health Inpatient Equity Act (HR 6143)

Medicare Part D Benefit Update: 2011 Open Enrollment Period Set to Begin
1/02/2010
Open enrollment for the Part D prescription drug benefit program will begin on November 15, 2010 and run through December 31, 2010.

Medicare Drug Benefit Update: 2010 Plan Year Enrollment Begins
11/19/2009
This week marks the start of the open enrollment period for the Medicare Part D drug benefit for 2010. The "open season" period for 2010 drug plan enrollment runs through December 31.

NAMI Comments on Medicare Part D Regulations on Drug Formulary Coverage Rules
3/23/2009
Read NAMI's comments on Federal regulations related to the Medicare Advantage and Medicare Prescription Drug Programs MIPPA Drug Formulary and Protected Classes Policies.

NAMI's Letter of Support for HR 6331
7/10/2008


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NAMI's Position on the Issue:

NAMI Presses CMS to Ensure that Atypical Antipsychotics are Included in the Upcoming Medicare Part B Competitive Acquisition Program (CAP)
Earlier this year, NAMI pushed the Centers for Medicare and Medicaid Services (CMS) to include atypical antipsychotic medications in the Part B CAP program covering non-self-injectible medications administered in physician offices and clinics.

The New Medicare Drug Plan and Beneficiaries with Mental Illnesses
The new Medicare drug benefit will help seniors and people with disabilities who receive Medicare benefits by providing coverage for prescription drugs. Frequently asked questions regarding the benefit, which may be of particular interest to beneficiaries with mental illnesses, are answered in this document.

Bob Dole on the New Medicare Drug Benefit
Bob Dole supports the new Medicare drug benefit for seniors and people living with disabilities.


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Take Action!

Contact Your Representatives about Medicare
Use our online advocacy tool to send a letter to your elected officials right now and make your voice heard on this issue. Use our suggested text or compose a letter of your own.

Sign Up for E-News Alerts
Keep up with the latest developments on this issue by subscribing to NAMI E-News, our free action alert newsletter.



Other Resources:

New Resources on the Medicare Part D Coverage Gap
Two new brochures from YourPharmacyBenefit.org can help you understand the Medicare part D coverage gap and how to effectively deal with it.

Medicare Interactive Website
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What If Sheet - after Transition Period pdf
Medicare Part D "What if sheet" for issues after the Transition Period Ended on March 31, 2006

Quick Answers to FAQs on Processing Claims for Dual Eligible Beneficiaries
Learn more about what to do if there are problems with filling prescriptions by dual eligibles enrolled in the new Medicare Part D.

MAPRx Website Now Available
The MAPRx (Medicare Access for Patients Rx) website is now available to help you navigate through the Medicare Prescription Drug Coverage plans.

Partnership for Prescription Assistance
A new toll-free number and Web site provide help to those who lack prescription coverage or cannot afford their medications.

NAMI Policy Research Institute
Learn more about NAMI's Policy Research Institute, whose mission is to drive national, state, and local debates on reforms and investments in the nation's mental illness delivery and financing system.

Medicare Prescription Discount Card Now Available
As of June 1, savings on prescription drugs became available to Medicare beneficiaries under the Drug Discount Card program.

NAMI Position on Medicare Conference Report
The new benefits for prescription drug coverage and protections for vulnerable, low-income beneficiaries (including those dually eligible for both Medicare and Medicaid) appear to be a major improvement over the status quo and previous congressional proposals. As a result, NAMI has sent a letter to House and Senate leaders urging members to vote in favor of passage later this week.

The New Medicare Drug Plan and Beneficiaries with Mental Illness
On December 8, 2003, President Bush signed into law the Medicare Modernization Act - a new law expanding the Medicare program to offer coverage for outpatient prescription drugs. While few of the new law's provisions apply solely to Medicare beneficiaries living with mental illness, the expanded coverage includes many changes that will impact the way Medicare is able to pay for mental illness treatment. This document contains commonly asked questions and answers about the how the new law will affect beneficiaries with mental illness (both elderly and non-elderly Social Security Disability Insurance (SSDI) beneficiaries).


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