Medicare and Obamacare – Bits and Pieces

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Medicare and Obamacare

Medicare Therapy Services Broaden: on 5/30/2014 The New York Times , Carrns, Subscription Publication) reports on evolving Medicare policy for treatments like physical therapy and occupational therapy. For years, “the prevailing approach was that if the therapy was not helping to improve a patient’s condition, then it was not eligible for coverage.” Now, though, that “is changing,” following “a 2013 settlement of a lawsuit that the center and others brought against the secretary of the Health and Human Services Department.” Revisions to HHS’ policy now state that payment cannot be denied “if treatment is needed to prevent or slow further deterioration in a patient’s condition.”

Before this change is implemented, therapy had to show the patient was improving from therapy. This should open the door for future therapy to help people on Medicare where therapy can he slow the deterioration in the patient’s condition. Usually, insurance companies follow Medicare’s lead. Therefore, in the future more therapy services may be to people not on Medicare.

Obamacare (ACA) – 25% of the enrollees have discrepancies in their application: on 6/4/2014 The AP (Alonso-Zaldivar) was the first to report that “at least 2 million people enrolled for taxpayer-subsidized private health insurance under the ACA have data discrepancies in their applications that, if unresolved, could affect what they pay for coverage, or even their legal right to benefits.” The article defines “discrepancy” to mean that the information supplied by the consumer “does not match what the government has on record.” The data conflicts mostly “involve important details on income, citizenship and immigration status – which affect eligibility and subsidies.”

This writer has found that people have found the enrollment process confusing; especially if their situation falls a bit outside of the norm. In addition to selecting a plan which is right for them, income changes are; and will become one of the biggest problems for people. People whose income falls below 138% of federal poverty level (FPL) of any year will need to report this change to the ACA. If they do not, they may need to repay subsidy monies received that assisted them with their premium. Conversely, if a person’s income increases; one could have a reduced subsidy, or lose their subsidy completely and need to repay the government.

If you have any change in income, employment status, your spouse’s employment status, dependent status, get married/divorced, or become eligible for employee sponsored coverage; you should notify the ACA. Other situations may occur where you should notify the ACA.

Observation bed admissions verses inpatient admissions: If you are on Medicare, continue to be aware that not all hospital stays are considered hospital admissions. Insurance policies pay differently for observation bed verse inpatient admissions. This could mean more money out of pocket if you have a Medicare Advantage plan (for the hospital bill) or non-payment for a following skilled nursing home stay (Original Medicare has a s 3 day hospital inpatient stay requirement). Medicare Advantage Plans usually do not have a 3 day inpatient stay requirement, but still only pay for a very high level of skilled care in a nursing home.

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Steven A. Buttice is the president of Medical Reimbursement & Management Services, Inc., a firm specializing in issues affecting seniors, including seminars and consultation on Medicare Plans, Long Term Care and other types of insurance, claims issues, and sales/service of insurance products since 1984.

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