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Medicare Coverage for Mental Health Services: What You Need to Know

At some point in life, many of us experience a need for mental health services. And in a lot of cases, those circumstances come after retirement. Once the kids have left home, you’ve left your career, and your social life changes, feeling like depression and anxiety can surface. Many Medicare beneficiaries are uncertain of their treatment options, and might wonder about Medicare coverage for these services. Here’s what you need to know.

Medicare coverage includes preventive services for mental health. We all know that preventing a health condition is often easier, and wiser, than attempting to treat one after the fact. So along with other types of preventive services, Medicare offers screenings for mental health conditions:

  • A “Welcome to Medicare” visit within your first year of coverage, which includes an assessment for your depression risk
  • Annual depression screening via your primary care doctor
  • Alcohol misuse screening (one per year)
  • Annual wellness exams, during which you can talk to your doctor about mental health symptoms or concerns, or ask for a referral if necessary

Medicare coverage includes treatment for mental health conditions. If prevention fails, Medicare does offer coverage for a variety of mental health treatment options. The following services are offered on an outpatient basis:

  • Psychiatric testing and diagnoses
  • Therapy -both individual and group, depending upon your needs and preferences
  • Family therapy in some situations
  • Up to 4 sessions of alcohol abuse counseling

Medicare coverage does extend to inpatient services. In some circumstances, a patient might need more intensive mental health care. Medicare Part A does cover hospitilization, up to 190 days in your lifetime. Medicare Part B will cover services that you receive during your stay in the hospital.

Medicare coverage can help pay for certain medications. Yes, antidepressants and other medications used for mental health conditions can be covered by your Medicare plan. However, because Part D and Medicare Advantage formularies (lists of covered drugs) do differ from one plan to another, it is wise to check your list of covered drugs each year during the enrollment period. Taking this step will help you to maintain a plan that covers the prescriptions you need for your condition.

If you have any other questions about Medicare coverage for mental health services, please contact one of our helpful representatives. We can help you compare and shop for Medicare plans that best suit your needs.


Understand Your Rights With Regard to Mental Health Care

Gone are the days in which mental health care was not treated with the same level of importance as care for physical health issues. These days, both the Affordable Care Act and California law set forth minimum standards for health care plans and providers, so that those needing treatment can seek and receive the services they require.

But as with anything else, knowing your rights is the key to accessing them. So here is what you need to know about mental health care and the law.

Under the ACA, mental health services are deemed “essential”, meaning any plan that seeks to be ACA-compliant must provide a certain level of care in this area of health. Services that must be provided under the plan include:

  • Treatments such as counseling and psychotherapy
  • Inpatient mental and behavioral health services
  • Substance abuse treatment

These meantl health services are subject to the same standards as medical and surgical care in how care is managed and how deductibles and co-pays are applied.

Additionally, California law supplements ACA requirements by specifying a number of specific conditions for which care must be provided:

  • Major depressive disorders
  • Autism or pervasive developmental disorder
  • Bipolar disorder
  • Panic disorder
  • Schizophrenia
  • Schizoaffective disorder
  • Obsessive-compulsive disorder
  • Anorexia nervosa
  • Bulimia nervosa
  • Serious emotional disturbances in children under age 18

California healthcare plans must cover inpatient and outpatient treatment, as directed by the overseeing doctor, and prescription drugs when needed.

Finally, if you seek an intial consultation for mental health care, California law requires that the provider or facility provide you with a return appointment within 10 days. The same deadline applies to referrals for mental health care from your primary care provider.

We are fortunate that the law does take mental health seriously, and that we can all obtain care when we need it. Just as with any other healthcare need, seek services promptly when you need them to protect your health. And if you’re ever in doubt as to how your healthcare plan works, or what type of treatment it covers, contact your plan provider’s customer service team.

3 Benefits of an Independent Insurance Broker

When you’re shopping for an insurance plan, you face an important choice right away. Should you consult with an independent insurance broker, or what’s called a “captive agent”? Here’s the difference: An independent insurance broker contracts with many different providers, whereas a captive agent works for just one insurance company.

If you choose to work with an independent insurance broker, you will reap several valuable benefits…

Access to a wide range of insurance providers and plans. This can be especially important with regard to health insurance and particularly Medicare plans. You want a plan that truly suits your healthcare needs, while fitting into your budget with regard to things like copayments, premiums, and deductibles. Because health insurance and Medicare plans can vary so widely from one another, the ability to shop amongst numerous insurance carriers can only provide you with better options.

Customer support. Independent insurance brokers enjoy additional training, education, and support resources, the benefits of which are passed on to you. Your independent agent will reach out to you regularly with helpful blogs and/or email newsletters to keep you informed of your options. And it always helps to consult with a friendly face right in your own hometown, rather than an anonymous stranger over a nationwide 1-800 number.

Flexibility. Because independent insurance brokers are self-employed and make their own schedules, they are often available at more flexible hours and locations. This can be of great help to the busy professional who needs personal assistance that fits into their lifestyle.

As you’re shopping for a health insurance plan, Medicare plan, or any other type of insurance, keep these points in mind. Give us a call, and we will demonstrate the benefits of working with an independent insurance broker so that you can judge the difference for yourself.


Why an HSA Could be a Good Choice for You

For those with high-deductible healthcare plans, low monthly premiums can also mean high out-of-pocket expenses. These plans are often thought to be the right choice for those who are unlikely to experience significant health problems, or employers who cannot afford to provide a more expensive, low-deductible plan. But when health problems do strike, they can wipe out an individual’s financial resources. A health savings account (HSA) is the answer to that problem.

What is an HSA? A health savings account works like a savings account, but the money in it will be strictly used for covering out-of-pocket healthcare expenses. They can be paired with low-premium, high-deductible healthcare plans, to help employees save up to meet their deductibles and other costs.

An HSA provides certain tax advantages. An HSA is funded via automatic contributions from the employee’s paycheck, on a pre-tax basis. This means that the funds used to cover their out-of-pocket healthcare expenses are not taxed, and the employee’s overall income tax liability is lowered by the amount of their HSA contributions for the year. This can provide a significan tax benefit to workers while helping them to budget for large medical expenses.

HSA funds roll over from one year to the next. If funds within the HSA are not used in a particular year, there is no risk of losing the money. It simply rolls over to the next year. In fact, because the HSA stays with the employee and rolls over each year, they can even take it with them into retirement. At that point the money can be used to cover Medicare premiums or out-of-pocket healthcare expenses like prescription medications, making HSAs another way to prepare for the future.

What is the HSA contribution limit? In 2022, individuals can save $3,650 and those with family healthcare plans can save $7,300 in their HSA.

What if my employer does not offer an HSA? You can still open a health savings account through any bank that offers one. Then, you can fully deduct your contributions on your tax return each year.

To learn more about HSAs and how they can help you and/or your employees, give us a call and we’ll help you evaluate the possibilities.

Medicare Coverage for Dental and Vision Care

As you plan for retirement, you might expect that Medicare will cover all of your necessary medical service. Unfortunately, that isn’t the case. Depending upon the type of Medicare plan you choose, you will probably end up paying out of pocket for at least some of your healthcare. That is especially true with regard to dental and vision care, especially if you enroll in Original Medicare (Medicare Parts A and B).

Here’s what you need to know: Original Medicare does not cover dental and vision care, except in certain (and very limited) emergency situations. Generally speaking, you will have to pay your dentist and eye care professional yourself. On the other hand, some Medicare Advantage plans do offer coverage for these services.

Medicare Advantage plans are contracted through private insurance companies, who can put together their own package of coverage. Advantage plans cover everything offered through Original Medicare, but often with the addition of other types of services such as dental and vision care. However, each Advantage plan is different, and you will usually pay a monthly premium for these plans (unless you choose a $0 premium plan, which is sometimes possible).

Vision care offered through Medicare Advantage plans will generally include preventive screenings, routine eye exams, and corrective lenses.

Dental care offered through Medicare Advantage will often include the following, although plans might differ:

  • Routine dental exams
  • Dental X-rays
  • Routine teeth cleanings
  • Fillings
  • Tooth extractions
  • Root canals
  • Gum disease treatment
  • Dentures
  • Dental implants
  • Bridges
  • Crowns

To learn more about which Medicare Advantage plans offer coverage for dental and vision care, and what that coverage looks like, call one of our insurance professionals. We can help you assess your budget, evaluate different plans, and choose one that suits your needs and budget.

Warning: Income Changes Can Impact Health Insurance Subsidies

If you receive a subsidy to help pay for your health insurance premiums, you probably already know that these subsidies are calculated based upon your household size and income. But what you might not know is that errors regarding those calculations can lead to an unpleasant surprise later.

Each year, your subsidy is calculated based upon your anticipated income for the year. Those subsidies are then paid directly to your health insurance provider, as Advanced Premium Tax Credits (APTC) each month. But if your income exceeds expectations for the year, and your the APTC paid is larger than it should have been, then you will owe the difference when this discrepancy is discovered. This generally happens when you file your income tax return, which reflects your true income for the year. If you received a raise during the year, your spouse’s employment situation changed, or if you worked a lot of overtime, you could earn more than the original estimate of your annual income.

Certain limitations do apply to the repayment demand, according to IRS rules, so you might not owe the full balance. However, this is a situation that you definitely do not want to risk! No one wants to discover that they unexpectedly owe hundreds or even thousands of dollars.

Luckily, there is a simple way to avoid this unpleasant situation. Simply keep track of your income throughout the year, and update the system if it looks like your earnings will exceed the original calculation of your expected income. Log into to update your earnings record, so that your subsidy can be recalculated to reflect your true income.

If you have more questions about health insurance subsidies or how they are calculated, give us a call so that we can assist you. The system can be confusing at times, but with professional assistance you can maintain health insurance coverage while avoiding overpayments and subsequent repayment demands.

How to Manage the Cost of Prescriptions on a Fixed Income

Most of us expect to live on a fixed income in retirement, and we know that inflation will become a challenge to our budgets over time. What we often don’t expect, however, is that the cost of some necessary goods and services will outpace the overall inflation rate. And when one of those goods or services becomes essential for you, it creates a significant challenge for your budget.

That is now the case with prescription medications. The cost of many drugs has outpaced the general inflation rate for several years now, and many seniors have trouble affording their medications. According to the Office of Health Policy at the U.S. Department of Health and Human Services, 3.5 million Americans age 65 and older frequently struggled to afford their prescriptions in 2019. Many report that they are skipping doses of their medications, or halving their pills, in order to make ends meet. 

Other statistics reported by HHS include:

  • Black and latino Medicare recipients over the age of 65 were 1.5 to 2 times more likely to have trouble affording their prescriptions
  • Gender also impacts affordability of prescription drugs, with 7.8 percent of women and 5.2 percent of men reporting problems
  • Among Medicare recipients with diabetes, 9.9 percent of seniors over age 65 reported problems with affording prescriptions, compared with 6.6 percent of the overall over-65 population
  • 11 percent of seniors living below 200 percent of the poverty level report affordability issues, compared with 4.7 percent of seniors living above 200 percent of the poverty level

Congress continues to debate various measures to control the cost of prescription medications. But Medicare does offer the opportunity to participate in Part D, or prescription drug plans, to assist you with the cost of prescription drugs.

Enrolling in a plan can help you to manage out-of-pocket spending on prescription medications, but the real key is using your plan appropriately. Each year during the annual election period, research the different plans available to you. Make sure you understand each plan’s drug formulary, talk to your doctor about affordable medication options, and stay current on changes to your plan each year. Using generic drugs will almost always result in a significant savings, so make sure to always tell your pharmacist of this preference. Taking these steps can help you to maximize the benefits from your Part D plan.

Good Rx provides resources to help you manage your prescription drug costs. Their app monitors prices of medications with more than 75,000 pharmacies in the United States. You will also receive coupons for discounts on some medications. The service even provides a telemedicine platform so that you can discuss your prescription needs without having to visit the doctor in person.

If you need help understanding your Part D plan, or comparing plans and shopping for one, give us a call. We can help you identify your needs and then match you to a Medicare Part D plan that helps you manage your spending.

Turning 65 This Year? Do These Three Things!

If you’re turning 65 soon, retirement planning has kicked into high gear. This is a milestone age for many people, because you need to make three important decisions around this time. So if your 65’th birthday is approaching, make sure to put these items on your to-do list.

Get an estimate of your Social Security benefits. Your Social Security benefits are based upon a specific formula used by the Social Security Administration. An experienced financial planner or a Social Security representative can help you with this step. Since your retirement income will be based partly upon your Social Security benefits, you definitely want to obtain an accurate estimate of what you can expect. Your financial professional or Social Security representative can also help you to understand the potential benefits of delaying your claim a few more years to earn a larger monthly check.

Consider income taxes after retirement. If you’re getting ready to retire, remember that income taxes will still be a part of your financial plan even after you stop working. Meeting with a financial planner or tax professional can help you to anticipate your potential tax burden, so that you don’t face any surprises after you retire.

Investigate your options an enroll in Medicare. When you turn 65, you must enroll in Medicare (unless you still have health insurance coverage through an employer, in which case you can opt into Medicare as co-insurance, or not). But enrolling in Medicare can be a complex decision. You will choose between Original Medicare or a Medicare Advantage plan. Plus, your original enrollment window is the best (and possibly only) opportunity to obtain a Medigap plan. So take this time to investigate all of your options, and enroll in a Medicare plan (or plans) that work best for your situation. And remember, you can change your mind each year during the Annual Election Period or Medicare Advantage Open Enrollment.

For more information on your Medicare options, give us a call. We can help you understand the different plans available to you, and guide you toward the choices that suit your needs and budget.


Here’s What You Need to Know About ACA Compliance Deadlines

Now that tax season has arrived, both individuals and employers must take certain steps to demonstrate proof of health insurance coverage. Yes, the penalty for failing to comply with the ACA is set at 0 dollars at the federal level, but documentation of coverage is still required. And now that California has instituted its own mandate, you will need to complete these requirements for your state taxes as well.

If you receive health insurance through Covered California… You need to file Form 1095-A when you do your taxes. Watch your mailbox; this form should arrive by the deadline of January 31.

If you enroll in health insurance directly through an insurance carrier, or you’re on Medicare… You should receive Form 1095-B by January 31. This is the form you will file with your tax returns.

In both cases, your insurance carrier is responsible for sending you these forms.

If you’re covered by a group health insurance policy, and your employer has 50 or more full-time employees… You will need to file Form 1095-C with your tax returns. Your employer is responsible for giving you this form, and might do so in person, by mail, or by email if you have given consent. They must complete this step by January 31.

File your taxes by the end of the day on Monday, April 18. This is the deadline for everyone, regardless of employment or health insurance status. You can file with a paper return, or online using tax software.

If you don’t have everything you need, or you need more time to complete your tax return for some other reason, you can request an extension. Then you have up to six months to finish your return. However, you must request the extension by the same date (April 18) or else face penalties and possible fines for failing to file.

However and whenever you choose to file your taxes, keep a copy in your files. Keep your 1095 form, too, so that you can provide proof of health insurance coverage if it is requested.

If you need more assistance understanding ACA compliance and tax filing requirements, give us a call. We will be happy to answer your questions.


5 Things You Can Do During Medicare Advantage Open Enrollment

Now that the new year has begun, are you feeling satisfied with your Medicare plan? The Annual Election Period came and went, closing down on December 7. But for those enrolled in Medicare Advantage plans, you have another opportunity to change to your plan if needed.

From January 1 to March 31, the Medicare Advantage Open Enrollment period allows you to reevaluate your plan and make certain changes. If you’re feeling less than certain about your plan, you can take the following actions at this time:

  • Investigate the details of your Advantage plan, such as covered providers and the drug formulary, to determine if this is still the right plan for you
  • Shop around, comparing other Medicare Advantage plans that are available in your area, to see if one might suit you better
  • Drop your Medicare Advantage plan and enroll in a different Advantage plan, if you find a preferable one
  • Drop your Advantage plan and go back to Original Medicare
  • Add a Part D (prescription) plan if you do go back to Original Medicare

Keep in mind that Medicare Advantage Open Enrollment applies to those enrolled in Advantage plans only. If you’re currently enrolled in Original Medicare, you can’t make changes during this time (unless you qualify for a Special Enrollment Period, which is another type of enrollment).

Also, any changes you make will take effect on the first of the month following the month in which you make the change. So, for example, if you switch to a new Medicare Advantage plan on January 20, the new plan will take effect on February 1.

To learn more about what you can do at this time, contact our office to speak to a Medicare specialist. We can help you determine your next steps, and compare Advantage plans to find one that fits your needs and budget.



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