National Training Program

1. National Training Program Medicare and - Health Savings Accounts The Windsor Ruling Mental Health Services June 2014

2. Disclaimer This CMS National Training Program product isn’t a legal document. Official legal guidance is contained in the relevant statutes, regulations, and rulings.

3. What is a Health Savings Account (HSA)? • A tax-exempt account to pay for certain medical expenses you incur • Must be in conjunction with a high-deductible health plan (HDHP) • You own the account, but both you and your employer can contribute funds • Tax-advantages: contribute pre-tax money, funds accrue tax-free and you may withdraw funds tax-free (for eligible medical expenses)

4. What are the benefits of an HSA? • You can claim a tax deduction for contributions you, or someone other than your employer, make to your HSA • Tax-free withdrawals for qualified medical expenses • Account earns interest tax-free • Unused funds and interest carry over from year to year • The account is owned by you and is yours to keep even if you change employers or leave the work force

5. Treasury Rules on HSA Eligibility • To be eligible you • Must be enrolled in an HDHP • Can’t be enrolled in Medicare • Can’t have received VA benefits in the past 3 months • Can’t be covered under any non-HDHP health plan • Can’t be claimed as a dependent on someone else's tax return

6. High-Deductible Health Plan • HSAs can only be offered with a high-deductible health plan (HDHP) • High deductible - lower monthly premium • HSA funds can pay for medical expenses subject to the deductible • HDHP must provide the following coverage in 2014:

7. 65 and Older • Individuals 65 and older: • HSA distributions can be used for non-qualified medical expenses • Without facing the 20 percent penalty • Income taxes will apply for non-medical distributions • Regardless of whether the individual is enrolled in Medicare

8. Health Savings Accounts and Medicare • You can’t contribute to an HSA in any month that you’re enrolled in Medicare • Stop contribution 6 months before enrolling in Medicare if entitled to Part A, but not enrolled at 65 • Funds remain yours to spend tax-free on qualified Medical expenses including Medicare Part A, B, and D premiums, deductibles, and copayments

9. Resources • IRS Pub#969 irs.gov/publications/p969/ar02.htmlIRS • Pub#502 irs.gov/pub/irs-pdf/p502.pdf

10. The Windsor Ruling • June 26, 2013: United States v. Windsor • The Supreme Court ruled that Section 3 of the Defense of Marriage act (DOMA), as outlined in 1 U.S.C. § 7, is unconstitutional • The Federal government is no longer prevented from recognizing same-sex marriages

11. Effect of Ruling on Medicare • We can recognize some same-sex marriages • Medicare • Social Security benefits • Retirement • Social Security Disability Insurance (SSDI) • Supplemental Security Income (SSI)

12. Medicare Entitlement • People who are entitled to Social Security benefits become entitled to Medicare (i.e., free Part A): • 65 • Disability (after 24 months of SSDI) • Also applies to people who are entitled to spousal benefits

13. Medicare Entitlement • Most applications for Medicare require a determination about Social Security benefits • Must determine entitlement to retirement benefits or number of quarters of coverage when processing Medicare claims to see if the individual gets free Medicare Part A • Social Security processes almost all Medicare applications for CMS (the rest processed by RRB)

14. Medicare Entitlement • Can get free Part A anytime after end of initial enrollment period (IEP) if entitled (based on self or spouse’s earnings) • No late enrollment penalty for free Part A • Can’t enroll in Part B anytime

15. Medicare Enrollment • Enrollment is not the same as entitlement • Medicare Part B/Premium Part A rules differ from free Part A rules • Must be in a valid enrollment period; can only enroll during Initial Enrollment Period, General Enrollment Period, or Special Enrollment Period • May have a late enrollment penalty

16. Special Enrollment Period (SEP) • SEP eligibility for Part B/Premium Part A • Have Group Health Plan (GHP) coverage based on own or spouse’s current employment • If disabled, have coverage based on family member‘s current employment • Must have coverage for all months eligible to enroll in Part B/premium Part A, but didn’t • Individual can use SEP while all factors are met and for up to 8 months following the loss of current employment or loss of GHP coverage, whichever occurs first

17. Special Enrollment Period (SEP) • SEP rules differ from entitlement rules • Rules for treating as a spouse for SEP include: • Legal marriage at time of request to SSA • The individual or spouse can live in any State (doesn’t matter if State recognizes same-sex marriage) • Domestic partnerships/other legal relationships that are not legal marriages are not treated as marriages • SEP for working disabled (under 65) also includes family members, not just spouses • Family members include domestic partners

18. Premium Surcharge Reduction • Premium surcharges assessed by law for late enrollment (Part B/Premium Part A) • For individuals who enrolled in General Enrollment Period but had GHP coverage • Can request premium surcharge reduction at any time • Premium surcharge for Part B/Premium Part A can be reduced partially or fully • Calculation of reduction uses the number of months of GHP coverage based on own or spouse’s current employment

19. Premium Surcharge Reduction • Rules for recognizing spouse for premium surcharge reduction match the SEP rules: • Legal marriage at time of request to SSA • The individual or spouse can live in any State (doesn’t matter if State recognizes same-sex marriage) • For working disabled (under 65) also includes family members, not just spouses

20. Domestic Partners • For SEP and premium surcharge reduction, domestic partners/civil unions are not considered spouses • SEP and premium surcharge reduction rules differ from Medicare entitlement rules • Treat same-sex marriages and opposite sex-marriages the same way

21. Processing of Requests • SSA can now process all requests for SEPs and premium surcharge reductions • Some same-sex claims for Social Security benefits and Medicare entitlement are being processed • We continue to work with the Department of Justice to develop and implement additional policy and processing instructions

22. Held Requests • If the claim is unable to be processed, individuals need to cover their health care costs out-of-pocket while the claim is held • If approved • Medicare coverage start date will be based on filing date and when eligibility was met • Can submit health care claims back to the date of Medicare entitlement for payment by Medicare

23. Resources • CMS Website: • medicare.gov/sign-up-change-plans/same-sex-marriage.html • SSA Website: • ssa.gov/same-sexcouples/ • Public listing of all policies • https://secure.ssa.gov/apps10/poms.nsf/subchapterlist!openview&restricttocategory=02002 • See section GN 00210 – Windsor Same-Sex Marriage Claims

24. Medicare Coverage for Mental Health • Mental health conditions, like depression or anxiety, can happen to anyone at any time. • Talk to your doctor or health care provider if you have: • Thoughts of ending your life • Sad, empty, or hopeless feelings • A lack of energy • Trouble concentrating • Trouble sleeping • Little interest in things you used to enjoy • Weight loss or loss of appetite • Increased use of alcohol or other drugs

25. What’s covered Under Medicare Part A(Hospital Insurance) • Helps pay for mental health care if you’re an inpatient in a general or psychiatric hospital • Room, meals, nursing care, and other related services and supplies • If you’re in a psychiatric hospital (instead of a general hospital), Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime

26. Your Cost Under Medicare Part A • For inpatient mental health services, you pay: • A one-time hospital deductible for each benefit period ($1,216 in 2014) • Days 1-60: no coinsurance amount for each benefit period ($0 in 2014) • Days 61-90: a coinsurance amount per day of each benefit period ($304 per day in 2014) • Days 91 and beyond: a coinsurance amount for each “lifetime reserve day” after day 90 of each benefit period (up to 60 days over your lifetime) ($608 per day in 2014)

27. What’s Covered Under Medicare Part B(Medical Insurance) • Helps cover mental health services provided by doctors and other health care professionals if you’re admitted as a hospital inpatient • Also covers outpatient mental health services that you generally get as a hospital outpatient or outside of a hospital, including visits with these types of health professionals: • Psychiatrist or other doctor • Clinical psychologist • Clinical social worker • Certain other health care professionals

28. What’s covered Under Medicare Part B(Medical Insurance) continue… • Part B helps pay for these covered services: • One depression screening per year • Individual and group psychotherapy • Family counseling, if the main purpose is to help with your treatment • Certain lab and diagnostic tests • Psychiatric evaluations • Medication management • Certain prescription drugs, like some injections • In some cases, Part B may also pay for partial hospitalization services (an intensive, structured program of outpatient psychiatric services provided to patients as an alternative to inpatient psychiatric care)

29. Your Cost Under Medicare Part B • For most mental health services provided by doctors or other health care professionals (whether you’re an inpatient or outpatient) • You pay 20% of the Medicare-approved amount after the Part B deductible is met • If you get your services in a hospital outpatient clinic or hospital outpatient department, you may have to pay an additional copayment or coinsurance amount to the hospital • This amount will vary depending on the service provided, but will be between 20–40% of the Medicare-approved amount

30. What’s covered Under Medicare Prescription Drug Coverage (Part D) • Helps cover drugs you may need to treat a mental health condition. • Medicare drug plans are required to cover all (with limited exceptions) • Antidepressant, anticonvulsant, and antipsychotic medications, which may be necessary to keep you mentally healthy

31. Your Cost Under Medicare Part D • For prescription drugs: • The amount you pay will vary depending on the Medicare drug plan you have • If you have limited income and resources, you may qualify for Extra Help

32. Where can I get more information? • For more information about mental health services, visit mentalhealth.gov or contact • National Institute of Mental Health (NIMH), National Institutes of Health (NIH) – Visit nimh.nih.gov, or call 1-866-615-6464. TTY users should call 1-866-415-8051. • Substance Abuse & Mental Health Services Administration (SAMHSA) – SAMHSA has a treatment facility locator and a mental health services locator on its website. Visit samhsa.gov, or call 1-877-SAMHSA-7 (1-877-726-4727). TTY users should call 1-800-487-4889.

33. Where can I get more information? • Mental Health America – Visit mentalhealthamerica.net, or call 1-800-969-6642. TTY users should call 1-800-433-5959 • National Alliance on Mental Illness (NAMI) – Visit nami.org, or call the Information Helpline at 1-800-950-NAMI (1‑800‑950‑6264). • National Council for Behavioral Health – Visit thenationalcouncil.org, or call 1-202-684-7457. • If you need help now, call the National Suicide Prevention Lifeline (24 hours a day, 7 days a week) at 1-800-273-TALK (1-800-273-8255). TTY users should call 1-800-799-4TTY (1-800-799-4889).

34. This training module is provided by the CMS National Training Program For questions about training products, e-mail NMTP@cms.hhs.gov To view all available NMTP materials or to subscribe to our listserv, visit www.cms.gov/NationalMedicareTrainingProgram