With all of the changes that are taking place in healthcare we need to realize that Medicaid and Medicare are changing too.
What we know at this time is that Medicaid is continuing to remain in place for patients from age 0- 20, and will pay for rehabilitation during that time period, when prescribed by their treating medical professionals. The only other coverage for therapies for adults is in the outpatient hospital setting and then payment is made to the hospital and is subject to the Medicaid recipient's outpatient cap (limit).
The purpose of the therapy services program is to provide medically necessary physical therapy (PT), occupational therapy (OT), respiratory therapy (RT) and speech-language pathology (SLP) services to recipients from birth through age 20.
The therapy services program also provides services to recipients age 21 and older for SLP services pertaining to the provision of augmentative and alternative communication systems and PT and OT services pertaining to wheelchair evaluations and fittings.These are the only services in the therapy program that Medicaid reimburses for adults.
As far as Medicaid payment when secondary to Medicare, there is a very slim chance that Medicaid would ever make payment to a provider in that it would only be when the deductible is due if at all, since the Medicare payment is generally 80% of the Medicare allowed amount.
Once a patient's deductible has been met, the Medicaid fee is calculated at 50% of the Medicare fee in that situation.
Medicaid's policy regarding services that are covered by Medicare and not covered by Medicaid is as follows:
Cost Sharing overage for Medicare Part B Non-Covered Services:
Effective retroactive to October 1, 2010, there is a change in the Medicare Part B deductible and coinsurance for services not covered by Medicaid. The Medicaid rate for these services is established as 50 percent of the Medicare allowed amount. If Medicare pays more than the Medicaid rate, the Medicaid payment is zero. This coverage is available for Medicare recipients who are eligible for either:
- Qualified Medicare Beneficiary (QMB aid category), with or without any other Medicaid coverage; or
- Supplemental Security Income (MS aid category).
Please notify us through "Contact Us" with any questions. I am sure the Medicaid role and coverage will change as the healthcare changes take place. "Now, let's get going!" xo Sally
To learn more about the Occupational Therapy Services Sally Thimm OTR/L offers visit: Professional Case Management of SWFL
