Lynn Cooper was going through a terrible time. After losing his job in 2019, he became deeply depressed. Then the Covid-19 pandemic hit and his anxiety went through the roof. Then her cherished therapist — a marriage and family counselor — told Cooper she wouldn’t be seeing him after Cooper joined Medicare at age 65.
“I was shocked,” said Cooper, who lives in Pittsburgh and relies on counseling to keep her psychological balance. “I’ve always had the best health insurance for a person. Then I turned 65 and went on Medicare, and suddenly I had trouble getting mental health services.”
Problem: For decades, Medicare only covered services provided by psychiatrists, psychologists, licensed clinical social workers and psychiatric nurses. But with increasing demand and many people willing to pay privately for care, 45% of psychiatrists and 54% of psychologists do not participate in the program. Citing low payments and bureaucratic hassles, more than 124,000 behavioral health practitioners have dropped out of Medicare — the most of any medical specialty.
As a result, older adults worried about declining health or depressed due to the loss of family and friends have considerable difficulty finding professional help. Barriers to care are exacerbated by prejudice and ageism associated with mental illness, leading some health professionals to minimize the suffering of older adults.
Now, relief may be at hand as a series of legislative and regulatory changes expands Medicare’s pool of behavioral health providers. For the first time, starting in January, Medicare will allow marriage and family therapists and mental health counselors to provide services. This cadre of more than 400,000 professionals accounts for more than 40% of licensed mental health workers and is particularly important in rural areas.
Medicare is adding up to 19 hours a week of intensive outpatient care as a benefit, improving navigation and peer-support services for those with severe mental illness, and expanding mobile crisis services that can treat people in their homes or on the road.
“As we emerge from the COVID-19 public health emergency, it is abundantly clear that our nation must improve access to effective mental health and substance use disorder treatment and care,” Meena Sheshamani, deputy administrator of the Centers for Medicare and Medicaid Services, said in July. said in a statement.
Organizations that have advocated for years to improve Medicare’s mental health coverage applaud the changes. “I think, hopefully, we’ve reached an inflection point where we start to see more access to mental health and substance use disorder care for older adults,” said Deborah Steinberg, senior health policy attorney at the Legal Action Center in Washington, D.C.
For years, older people in need of mental health support have faced barriers. Although 1 in 4 Medicare recipients—including nearly 8 million people with severe disabilities under the age of 65—have some type of mental health condition, up to half do not receive treatment.
Cooper, now 68 and a behavioral health policy specialist at the Pennsylvania Association of Area Agencies on Aging, ran up against Medicare restrictions when she tried to find a new therapist in 2020: “My first problem was finding one. Who took Medicare A lot of providers I’ve reported to aren’t accepting new patients.” When Cooper finally found a clinical social worker willing to see her, the wait for an initial appointment was six months, a time she describes as “incredibly stressful.”
New Medicare initiatives will make it easier to care for people in Cooper’s position
Advocates also note the importance of expanding Medicare coverage for telehealth, including mental health care. Since the pandemic, older adults have been able to access these limited services earlier in the home by phone or digital device anywhere in the country, and the requirement for in-person appointments every six months has been waived. But some of that flexibility is set to end at the end of next year.
Robert Trestman, chairman of the American Psychiatric Association’s Council on Healthcare Systems and Financing, urged companies and regulators to maintain that expansion and reimburse mental health telehealth visits at the same rate as in-person visits, another pandemic innovation.
Older adults who seek mental health care tend to have more complex needs than younger adults, with more medical conditions, more disabilities, more potential side effects of medications and less social support, making their care time-consuming and challenging, she said.
Several questions remain open as Medicare implements these changes. The first is, “Will CMS pay mental health counselors and marriage and family therapists enough to actually accept Medicare patients?” asked Beth McGinty, chief of health policy and economics at Weill Cornell Medicine in New York City. It is by no means certain.
A second: Will Medicare Advantage plans add marriage and family therapists, mental health counselors and addiction specialists to their network of approved mental health providers? And will federal regulators do more to guarantee that Medicare Advantage plans provide adequate access to mental health services? Such surveillance has been spotty at best.
In July, researchers reported that Medicare Advantage plans cover an average of only 20% of psychiatrists within their network geographic areas. (Similar data are not available for psychologists, social workers and psychiatric nurses.) When older adults go out-of-network for mental health care, 60% of Medicare Advantage plans do not cover those costs, KFF reported in April. With high costs, many seniors simply skip services.
Another key issue: What will happen to Congress proposing mental health equity to advance Medicare? Parity refers to the idea that mental health benefits available through insurance plans should be comparable to medical and surgical benefits in major areas. Although parity is required for private insurance plans under the 2008 Mental Health Parity and Addiction Equity Act, Medicare is excluded.
One of the most egregious examples of Medicare’s lack of equity is the 190-day lifetime limit on psychiatric hospital care, a feature that profoundly affects members with serious conditions such as schizophrenia, major depression or post-traumatic stress, who often require repeated hospitalizations. . There is no similar barrier to hospital use for medical conditions.
An upcoming Government Accountability Office report examining differences in the cost and use of behavioral health services and treatment services in traditional Medicare and Medicare Advantage plans could give Congress some guidance, suggested Steinberg of the Legal Action Center. That investigation is ongoing, and a release date for the report has not been set.
But Congress can’t do anything about the all-too-common notion that seniors feeling overwhelmed or depressed “just have to grin and bear it.” Kathleen Cameron, chair of the executive committee of the National Coalition on Mental Health and Aging, said “we need to do more” to address biases around the mental health of older adults.
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