The cost of treatment to an individual for a mental health problem depends on such factors as type of treatment, therapist's training, treatment location and insurance coverage. Most older adults have Medicare. Many may also have insurance plans, sometimes called Medigap policies, that cover a majority of the expense. Unfortunately, Medicare does not cover most costs of long-term care for older adults who have Alzheimer's or similar diseases and require nursing facilities. It also only covers 50 percent of outpatient mental health costs.
Medical Assistance pays for treatment of mental health problems and for long-term care for low-income persons if it is determined to be medically necessary. People who qualify for Medical Assistance generally have a very small amount of co-payment or none at all.
What Are My Medicare Rights?
Many older adults are being offered insurance by managed care organizations, for example, Health Management Organizations (HMO), Managed Care Organizations (MCO), and Preferred Provider Organizations (PPO). While these insurance plans may offer good benefits, the buyer must understand what is and is not covered by each plan.
Having so many health care insurance options to consider can be somewhat overwhelming. The APPRISE Program helps persons who have Medicare or Medicaid health insurance questions.
All APPRISE services are provided free of charge. To talk to an APPRISE counselor in your area, contact Philadelphia Corporation for Aging, or call APPRISE at 800-783-7067. Also, if you need help with Medicare, you can call KePro (Medicare Insurance), 800-332-1914.
Every Medicare beneficiary has the right to:
- Receive good quality health care.
- Be admitted to the hospital when it is medically necessary.
- Stay in the hospital until it is medically safe to leave.
Many older adults aren't aware that they may be eligible for programs to help with their medical expenses.
Health Horizons is a program that helps with the medical expenses of adults 65 or over who have low income. The program will pay for medical benefits including prescriptions, doctor or clinic visits, dental and eye care. For more information on the program call Department of Public Welfare County Assistance Office 215-560-2900 or the Philadelphia Corporation for Aging 215-765-9040.
Prescription Drug Coverage
The cost of medication can be a huge barrier for many older adults in need of help. Unfortunately, many older adults will decrease their medication or stop taking it if it is too expensive. Here are some ways to get medication coverage or medication that is more affordable.
- Medical Assistance (MA): Depending on income and resources, many older adults may be eligible to have all prescription needs paid with no cost to them. The program can be reached at 800-842-2020.
- Explore Pharmaceutical Assistance Contract for the Elderly (PACE) or PACENET: If you are over 65, PACE is available to cover prescriptions (after a co-payment) for individuals with 2001 annual incomes below $14,000 for single persons and $17,200 for married couples.
PACENET is available to cover prescriptions, after a co-payment, for individuals with 2001 annual incomes between $14,000 and $17,000 for single persons and between $17,200 and $20,200 for married couples who have spent $500 on their prescriptions.
The PACE program can be reached at 800-225-7223.
Programs From Companies That Make or Distribute the Drugs
Most pharmaceutical companies have patient assistance programs through which people can get their prescriptions filled.
The first step is to find out the name of the manufacturer of the medication. Second, call the pharmaceutical manufacturer and ask if it has a patient assistance program. Ask what the requirements are for receiving free prescription drugs. Some companies require that the applicant have limited income or no insurance coverage at all in order to qualify for the program. Many companies require the applicant's physician to request participation in the program, and also to play a role in completing the application. Two Web sites offer information on contacting pharmaceutical companies: www.rxhope.com and www.phrma.org
Private Prescription Services
People can also obtain low-cost prescription drugs through a private prescription service. There are several. One is called www.needymeds.com and is an online service. The other is called Indigent Patient Services (IPS) and can be reached at 727-821-7333. These services usually charge a one-time registration fee and a cost per prescription and refill. For example, there might be a one-time registration fee of $25 and a $10 fee per prescription filled. The services require people to submit a request for each specific prescription drug that they need. They take phone requests and generate formal request forms that applicants and their doctors must sign and send to each pharmaceutical company. The pharmaceutical company will then send the medication to the doctor, who gives it to the applicant.
Discount Mail-order Services
Another way of getting lower cost medication is by contacting discount mail-order medication services. Here are just a few of the mail-order services to explore:
- Preferred Prescription Plan: 800-881-6325
- Managed Healthcare Systems: 954-938-7984
- RXUSA: 800-798-7248
Some offer prescription coverage, but policies vary in their degree of coverage. Before changing HMOs, make sure to ask a lot of questions. Some questions to ask are:
- Is there a monthly premium and how much?
- Does the HMO include my doctor in its network?
- What pharmacies would I have to use?
- Does the HMO cover my present prescription drugs on the formulary?
- If not, what is the cost to me for drugs that are not covered?
- Is there an annual limit on brand-name drugs?
- How is the limit calculated?
- Explain how the limit would be calculated in my case, given the drugs I take.
Many insurance companies offer policies that cover the gaps in Medicare coverage. These are called Medigap policies. The average Medigap policy covering prescription medications in Pennsylvania runs about $142 per month.
All veterans who have served on active duty in the Armed Forces, wartime or peacetime, and received an Honorable or General Discharge are eligible for medical care through the Department of Veterans Affairs, 800-827-1000.
Medicare Prescription Drug Discount Program
Medicare prescription drug discount cards are another way to save money on prescription drugs. This program is scheduled to operate between June 2004 and the end of 2005, when private companies will offer discount drug cards approved by Medicare. You will be able to buy a card that may save you some money on your prescription drugs. Like other drug discount cards the cards will offer discounts on only certain drugs. While similar to many discount cards available, Medicare endorsed cards must meet certain guidelines such as offering discounts on at least one drug in each therapeutic class. However, you will have to decide if purchasing the card is best for you.
What if I am low-income?
Individuals with incomes less than $12,569 (single) or $16,862 (married) and have no employer/retiree drug coverage are eligible for special benefits of up to $600 to help pay for drugs. They are able to get a card at no cost.
Should I get a Medicare drug discount card?
If you are eligible for the low-income discount benefits, it is definitely to your advantage because of the $600 that will be available for drug discounts. However, this amount will be reduced during 2005 as you get closer to the end of the program in December 2005.
Otherwise you must decide if the discounts you will receive, between 10 and 25% on some drugs will benefit you.
What should I know?
You do not have to get a Medicare drug discount card. There is no penalty for not getting one. The program is limited. Medicare discount cards may not offer discounts on all drugs. Each company's card will offer different discounts on different drugs. The list of the drugs discounted and the price for these drugs can change every week. However, you can only buy one Medicare card. In addition, Medicare discount cards will only work at certain pharmacies.
How do I get a Medicare drug discount card?
You can sign up with one of many companies that offer the card. However, because different plans offer discounts on different drugs, it is best to find drug discounts that match the drugs that you take.
Then sign up with the company that offers the benefits you want. Applications packages may be available at your pharmacy. There will be two kinds, one for the standard drug discount card and one for the special low-income benefits. The cost will be $30 for the standard card and no cost for the low-income one.
If your Medicare private plan, (HMO, PPO or PFFS) offers a discount card, you may only be able to joint that plan's discount card program. If you choose not to join it, you can still use any of the hundreds of other drug discount programs available that are not Medicare sponsored.
Where can I find a list of drug discount cards and how do I compare them?
A list of cards and a comparison tool are available on the internet at www.medicare.gov. You can also call 1-800-Medicare for assistance in comparing the Medicare drug discount cards.
Where can I get help?
Each county's Area Agency on Aging can direct you to a program to give advice on Medicare.
In Pennsylvania the program is called Apprise. In Philadelphia, the Apprise programs are located at the Mayor's Commission on Services to the Aging: 215-686-8462 for South and West Philadelphia; and Albert Einstein Medical Center's Premier Years Program: 215-456-7600 for the rest of Philadelphia.
Are there any websites on this?
One website, www.medicarerights.org has an interactive service on the Medicare plan and a listing of places to contact for discount information.