Medicare Options

Patients and providers need to be aware of the Medicare options. In the traditional fee-for service payment model, providers bill Medicare and Medicare reimburses providers for services provided. Generally, Medicare is available for people age 65 or older, younger people with disabilities. Medicare has two parts, Part A (Hospital Insurance) and Part B (Medicare Insurance). Patients may elect to keep what is referred to as “Original” Medicare. Patients can elect to obtain a secondary insurance to cover copays. Drug plans are a service provided by secondary insurance. Patients can elect to see a providers who are credentialed through Medicare. If a provider “accepts assignment”, Medicare is billed and Medicare determines the copayment. In addition, annual deductibles apply. Providers who accept assignment” are not allowed to “balance bill.” That means, the provider can only accept the copayment amount designated by Medicare. Providers who have taken Medicare in the past, can also “opt out” of Medicare. Instructions for “opting out of Medicare is available at Centers for Medicare and Medical (cms.gov)

Medicare Advantage plans are highly promoted. In Medicare Advantage plans, capitated payments are pre-arranged payments for healthcare providers to deliver services on a per member per month (PMPM) basis. Providers are paid a set amount for each patient they see, regardless of the costs each individual actually incurs. Advantage plans often have their own panels. While providers might be a provider for an particular insurance plan, the provider might not be on the Advantage plan for that particular heath plan. Bills go directly to the Advantage plan and copayments are set by the Advantage plan.

Medicare “open enrollment” is 10/15-12/7. Patients often switch from Original Medicare to an Advantage plan without a clear understanding of how the Advantage plan will impact their care. While it is important to get insurance benefits from all patients on 1/1/21, this can be confusing with patients who have Medicare. Patients may have been told that they can “keep their therapist” on the Advantage plan only to discover that the therapist is a Medicare provider and is not on the Advantage plan. There are some options. If therapy is in progress, the provider can ask the Advantage for a “Single Case Agreement.” Some Advantage plans allow the patient to apply for “Continuity of Care” within 30 days of starting the new health plan. If the patient has a Medicare Advantage plan that does not allow reimbursement for out of network providers, you may not be bound by the Medicare fee schedule unless you choose to be. The latter can be verified by the provider by contacting Medicare.

Between January 1–March 31 each year, a patient can make these changes during the Medicare Advantage Open Enrollment Period. If a patient is in a Medicare Advantage Plan (with or without drug coverage), they can switch to another Medicare Advantage Plan (with or without drug coverage). They can drop your Medicare Advantage Plan and return to Original Medicare. They are also able to join a Medicare drug plan. During this period, you, they can’t switch from Original Medicare to a Medicare Advantage Plan. A summary is available on line at the following,

Understanding Medicare Advantage Plans. - Medicare.gov

Patients can always call Medicare 800-633-4227. Noridian administers Medicare for CA. Providers can call Noridian 1-855-609-9960. Noridan also has a “hot line 1-866-575-4067.

Steven Tess, PhD, SDPA and CMH Committee member has written extensively on Medicare-Medical and Medicare Medi-Connect Plans. His articles have appeared in SDPA newsletters.

https://www.psychiatry.org › coding-reimbursement-medicare-and-medicaid

https://www.ncbi.nlm.nih.gov › pmc › articles › PMC4195086

The SDPA CMH committee meets every other month on the first Friday of each month from 1:30-3. We are currently meeting virtually. In addition to the SD Coalition for MH, we have representatives to two councils, Child Adolescent and Family as well as Adult and Older Adult. In addition, our members are all active in the community and bring information from their own work. We welcome new members.

Karen K Zappone PhD kzappone@san.rr.com

SDPA Community Mental Health Committee member, Andrea Karp, is a representative to the SD Coalition for Mental Health. At our bi-monthly meeting 8/8/20, Andrea shared that Jewish Family Services (JFS) has a card writing campaign. Residents in Skilled Nursing Facilities have been particularly affected by COVID-19. With all facilities currently prohibiting any visitation with the exception of end of life, many of the residents have found themselves even more lonely and isolated than before. JFS hopes to provide a warm hello with a hand written or hand decorated card to remind them they are not forgotten and they are thought about every day. Their goal is to deliver 6,815 cards for each of their clients in the 88 care facilities they serve. You supply your own cards. When you have finished, mail your unsigned cards to: Jewish Family Services, 8788 Balboa Ave ,San Diego, CA 92123 (858)637-3000. The SDPA CMH committee meets every other month on the first Friday of each month from 1:30-3. We are currently meeting virtually. In addition to the SD Coalition for MH, we have representatives to two councils, Child Adolescent and Family as well as Adult and Older Adult. In addition, our members are all active in the community and bring information from their own work. We welcome new members.

Contact Karen K Zappone kzappone@san.rr.com for more details.

More than 187,000 students have been exposed to gun violence since the Columbine shooting in 1999.  In approximately 200 separate incidents there was an approximate death toll of 130 plus another 254 injured. It is clear that something was very wrong mentally with the shooters. It is well past the time that we identify the potentially violent individuals and guarantee that they are involved in mental health treatment to prevent these massacres. But, wait a minute! Almost all the shooters were in mental health treatment at the time of their shootings! How could that be? There is a very disturbing May 20, 2018 article by David Kirschner, Ph.D in the National Psychologist. 

https://nationalpsychologist.com/2018/05/what-have-we-learned-from-30-years-of-school-shootings/104488.html

Since the 1988 Winnetka shooting by Laurie Dann, according to Dr. Kirschner, “The weapons have become infinitely more deadly, and the body count has mounted dramatically. But what have we learned? Dann had easy access to guns, as have all of the killers since then. And – similar to almost every school and mass shooter in the ensuing 30 years – she had a history of mental problems and was on psychotropic medication prior to and during the shootings.” Dann was on Anafranil, a tricyclic antidepressant, with listed side effects of “worsening hostile, aggressive and suicidal thoughts.” Almost every other school and mass killer since then had been in ‘mental health treatment’ prior to their shooting. Dr. Kirschner has interviewed more than 30 murderers and almost all of them were in “treatment,” mostly short term and drug oriented before they killed. He said, “While not the sole root cause (specific motivation and triggering events are different in each case), the use/abuse of prescription medications is the most consistent common factor – aside from easy access to guns – in almost every case of school and mass killings. These medications do not prevent, but instead contribute to homicide events by disinhibiting normal frontal lobe brain control mechanisms. Studies have reported a strong correlation between a person’s risk of homicide/suicide and use of these drugs, which may reduce anxiety or depression, but lessen/anesthetize frontal brain functions needed for forethought, impulse control, and empathy.” He said, “Almost every school shooter and mass killer has had “access” to mental health treatment based on drugs or short term, insurance-friendly psychotherapy, but the treatment received has been part of the problem, not the solution. Dr. Kirschner answers his own question, “What did we learn from 30 years of school shootings?”: NOTHING. 

Are there possible alternatives to using, according to Dr. Kirschner, dangerous stimulant and antidepressant drugs? Marilyn Wedge Ph.D posted the article, “Why French Kids Don’t Have ADHD on May 08, 2012. She said, “In the United States, at least 9 percent of school-aged children have been diagnosed with ADHD, and are taking pharmaceutical medications. In France, the percentage of kids diagnosed and medicated for ADHD is less than .5 percent.

https://www.psychologytoday.com/au/blog/suffer-the-children/201203/why-french-kids-dont-have-adhd

“In the United States, child psychiatrists consider ADHD to be a biological disorder with biological causes. The preferred treatment is also biological—psycho stimulant medications such as Ritalin and Adderall. French child psychiatrists, on the other hand, view ADHD as a medical condition that has psycho-social and situational causes. French doctors prefer to look for the underlying issue that is causing the child distress—not in the child's brain but in the child's social context. They then choose to treat the underlying social context problem with psychotherapy or family counseling.  The focus is on identifying and addressing the underlying psychosocial causes of children's symptoms, not on finding the best pharmacological band aids with which to mask symptoms.” There is an extensive discussion in child rearing patterns in the U.S. and France that could result in French children being better behaved than American children. This includes consistently enforced limits. The author concludes that French children don't need medications to control their behavior because they learn self-control early in their lives.

Exciting things are happening at the Community Mental Health Committee and the committee is accepting new members. Email CMHC Chairman Dr. Karen Zappone  kzappone@san.rr.com for meeting times.

SDPA members are involved as representatives in San Diego community mental health services as follows:

Children's Adult and Older Adult Mental Health System of Care Council, County of San Diego:  The purpose of the System of Care Councils is to ensure that all agencies serving San Diego County children, transition age youth, adult and older adult communities have coordinated services.  Coordination of care will result in outcomes consistent with System of Care values and principles.  The Council has its charge in providing on-going review, advice and comment on the implementation of the MHSA, and serves as advisory to the County Mental Health Director.  Sherry Casper, Ph.D. is SDPA representative and Mary Clark, Ph.D. is alternate representative for the Children's Council; Don Miller, Ph.D. is representative and Steve Tess, Ph.D. is alternate representative for the Adult Council; Jon Nachison, Ph.D. is representative for the Older Adult Council.

San Diego Mental Health Coalition:  This community group has representatives from consumer groups, family advocacy groups, county contracted organization professional provider groups, and is advisory to San Diego County Mental Health Services.  Andrea Karp, Psy.D. represents the SDPA and Laura Otis-Miles, Ph.D. is the alternate.

Optum Health Credentialing Committee:  This committee oversees the credentialing and re- credentialing of Optum Health's  Medi-Cal mental health providers to the public sector in San Diego County in response to the San Diego County Mental Health Plan's Quality Improvement Program.  Karen Zappone, Ph.D. is currently representative to this committee.

HOMELESSNESS

The Government Affairs Committee and several other psychologists had a Meet and Greet with San Diego County Supervisor Kristin Gaspar on 10/03/2017 at the home of Dr. Annette Conway, SDPA president at that time. These meetings with legislators give psychologists a valuable opportunity to discuss important mental health issues with influential decision makers. One of the topics was regarding prescription privileges for psychologists and Supervisor Gaspar shared some thoughts on the topic. Another topic of interest was homelessness. The Board of Supervisors is in charge of the San Diego County Mental Health yearly budget which is $182,226,222, with millions of that dedicated to the homeless. Supervisor Gaspar expressed some of her concerns. She said that millions of dollars were being spent on those who were already homeless. As she started asking around she found that not a lot of information was available about the people joining the ranks of the homeless. She started asking questions about what got them there, the entry, then exit and then return to homelessness. She was trying to take a closer look at people getting out of the military with no skills who end up homeless. Another population contributing to the homeless is a fair number of those getting out of prison. A large percentage of foster care graduates don’t go on to college, reducing their employment potential and increased potential for homelessness. Supervisor Gaspar’s focus on not only ways to service the homeless, but also her search for ways to prevent homelessness in the first place, was a fruitful bit of information she shared with the psychologists present at the 10/03/2017 Meet and Greet.

So, just what is San Diego County doing for the homeless? In July 2016 the County of San Diego County HHSA (Health and Human Services agency) BHS (Behavioral Health Services) presented a ten year roadmap. This was a major endeavor which seeks to address the most serious behavioral health issues affecting San Diego County over the next ten years. The goal of the Roadmap is to guide BHS planning to provide quality behavioral health services and to empower individuals with behavioral health needs to live healthy, safe and thriving lives. The roadmap is a dynamic living document updated annually to incorporate new priorities from community partners and HHSA/BHS leadership.

Twelve areas were identified including Aging Services, Crisis Services and the Homeless Population. Since one of the topics of the Meet and Greet was homelessness, the focus here will be on what is being done for the Homeless Population by the County BHS. Under Goals for the homeless, listed as “Priorities, Vision Statements and Strategies” it was noted that all persons with serious mental health and/or substance use disorders who are experiencing homelessness have treatment and housing to support their recovery.

Year One Accomplishments, in italics, follow the Goals presented in the Ten Year Roadmap.

1.   Ensure the appropriate level of care for homeless persons and implement an array of housing options that promote community integration.

        Implemented 245 treatment slots for homeless persons with Serious Mental Illness in support of Project One for All, as well as 145 treatment slots for homeless persons with Substance Use Disorders

        Housed 396 clients with Serious Mental Illness in permanent housing and bridge housing

         Added outreach and engagement services for 800 people in mental health and substance use disorder treatment programs to assess persons who are homeless and connect to appropriate BHS services and housing resources

2.   Work in partnership with housing authorities and developers to acquire permanent supportive housing.

        Paired 373 housing vouchers from San Diego Housing Commission (SDHC) and Housing and Community Development Services (HCDS) with BHS-contracted Full Service Partnership (FSP) Assertive Community Treatment (ACT) programs that serve homeless clients

        Connected 59 homeless BHS clients in outpatient treatment with HCDS housing vouchers

        Worked closely with housing partners to increase permanent housing stock for clients enrolled in FSP/ACT and outpatient mental health programs resulting in the creation of 47 permanent supportive units for BHS clients at the Hotel Churchill and Atmosphere housing developments (under the MHSA housing program)

3.   Reduce stigma through education, as well as incentivize and collaborate with landlords to increase housing inventory.

Worked with Housing and Community Development (HCDS) to educate and incentivize landlords to secure permanent supportive housing by offering a robust package to those who rent to formerly homeless persons that are connected with BHS services and have received an HCDS housing voucher.

This is an SDPA (San Diego Psychological Association) CMHC (Community Mental Health Committee) report on the San Diego County HHSA (Health and Human Services agency) by Don Miller, Ph.D, the SDPA representative to the Adult Behavioral Health System of Care Council.

The following information on the San Diego County efforts to address addiction takes on special significance for SDPA  since much of the focus of the SDPA fall conference is addiction. 

The HHSA 2018 budget is 1.9 billion dollars and they have reported that they have 43,000 Clients in treatment in a wide variety of programs, 11,000 are drug and or alcohol involved and in substance abuse treatment. The population of San Diego County is 3.3 million. There are ten thousand incarcerated individuals in San Diego County (5,600 in Sheriff Custody, almost 4,000 at Donovan). Two to four thousand of these incarcerated individuals have serious mental illness: Many are dual diagnosed, having alcohol/drug problems and mental illness. Over time, there has been the recognition that individuals suffering from mental health and or substance abuse conditions are often part of the revolving door phenomena. That is, after some kind of treatment or intervention, the same people show up again and again in the same condition. Jail recidivism and even separate episodes of homelessness are also example of the revolving door phenomena. HHSA, in collaboration with the courts, law enforcement, probation and wrap-around services, is searching for ways to break the revolving door cycle in multiple areas. A few of these programs are described here. If an individual who is registered in one of the four drug courts in San Diego County doesn’t show up for a follow up visit the probation department will pick them up for a one to three day stay in jail. Drug Courts, which involve 18 months of treatment/interventions instead of jail, have been found to be effective in the treatment of addictions. The SIP (Serial Inebriate Program) was designed as an intervention with homeless alcoholics who would be jailed overnight for public intoxication and be back in front of their favorite business the next day (which upsets the business owners). Graduated periods of involuntary rehabilitation (longer with each arrest, up to 180 days) have been successful in sobering up many repeat public alcohol intoxication offenders. The SMART Program (San Diego Misdemeanants At Risk Track) addresses an ongoing challenge to the criminal justice system in dealing with low-level misdemeanor offenders. They often cycle through the system without access to services, coordination of care or meaningful incentives to engage with social services. The SMART program has received a four million dollar grant and is similar to the SIP program and also uses progressive custody, like SIP but focuses on users of drugs, often heroin and methamphetamines. The SMART program provides intensive case management and care coordination along with tailored housing placements. Neighborhood House workers are going into the jails to recruit inmates into services, housing, rehab, even before they are released from jail. 

These programs, designed to break the revolving door phenomena, which some say basically involve involuntary treatment, have been found effective. The exciting thing to me about these intervention programs is that they resemble recommendations I have made regarding treatment for many years. My 1994 book, “Drug Wars: The Final Battle” recommended coordination between court, law enforcement, treatment facilities and close follow-up as aides to sobriety. Even my proposal “Teen Rescue” (as well as two other books) that can be found on my website drdonmiller.net, advocate close monitoring over extended time periods to ensure continued sobriety.

Here are some handouts for more information

HHSA Ten Year Roadmap Behavioral Health Services - accomplishments Year One

HHSA Ten Year Roadmap Behavioral Health Services - accomplishments Year Two

Exciting things are happening at the Community Mental Health Committee and the committee is accepting new members. Contact CMHC Chairman Dr. Karen Zappone at 619-291-6126 for meeting times. 

THE SDPA COMMUNITY MENTAL HEALTH COMMITTEE: HELPING RAISE COMMUNITY AWARENESS OF THE BENEFITS OF PSYCHOLOGY 

By Barbara J. Cox, Ph.D.

We at the SDPA Community Mental Health Committee are helping raise the general public’s awareness of how psychologists help make our society a better place by showing them the specific ways psychology can help. One of the ways we do get the word out is by sending representatives into the community to meetings and events, at such places as Behavioral Health Services (BHS) of San Diego County. Their mission at BHS, in a nutshell, is to efficiently provide services to the public that build strong and sustainable communities; a laudable goal which dovetails with all the wonderful things we as psychologists provide. We as representatives of the profession of psychology show that psychologists provide specialized tools and services that build strong and healthy communities.

I know that you as a psychologist are out in the community helping people achieve amazing things with their lives. If you would like to support our work, you can help build even more awareness of our profession just by doing one simple thing. Think of one person, group or organization that you have helped go on to do something positive in their families and neighborhoods.  If you can tell just one new person you meet this year, maybe at a holiday party or other such gathering, about the positive benefits of psychology that would go a long way to help us achieve our goals. In addition, if you would like to join us at our next meeting to consider becoming a member, exciting things are happening at the Community Mental Health Committee and the committee is accepting new members. Contact CMHC Chairman Dr. Steve Tess at 619-579-9346 for meeting times.

THE COMMUNITY MENTAL HEALTH (CMH) COMMITTEE'S PURPOSE is to involve itself in what's happening with the organizational delivery of mental health services to underserved populations in San Diego County.  The committee has representatives to the following organizations, agencies or coalitions:  Optum Health Credentialing Committee, the Adult Council of Care, the Children's Council of Care, and the San Diego Coalition for Mental Health.  We are looking to find a representative to TERM.  The representatives go to meetings to obtain information on what's happening with that particular organization, agency or coalition as well as to provide input that hopefully represents the interests of psychologists.  Besides myself, the other current members of CMH are Sherry Casper, Ph,D, Mary Clark, Ph.D., Barbara Cox, Ph.D., Andrea Karp, Ph,D., Don Miller, Ph.D., Laura Otis Miles, Ph,D., Alexa Rabin, Psy.D., and Karen Zappone, Ph.D.   We meet every other even month on the first Friday from 1:30 - 3:00 pm at Kings Fish House restaurant in Mission Valley.  We are always looking for additional members.  Our next meeting is Friday August 4.  Steve Tess, Ph.D. Chair