Insurance Updates (3)
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
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2016 Health Insurance Open Enrollment: What you need to know.
Written by Janelle Kelly-Joyce
Each year around this time, everyone enrolled in an individual or family health insurance plan, has the option of “Open Enrollment.” This allows you to view and shop for alternate plans with your selected insurance company or consider alternative health insurance through the policies offered through www.Healthcare.gov. Medicare options for Open Enrollment ended December 7, 2016.
Here Are Some Helpful Tips to guide you through “Open Enrollment”:
- The Open Enrollment Period is From November 1, 2015 – January 31, 2016.
- Important dates for 2016 enrollment:
- If you do not enroll in a health insurance plan by January 31, 2016, you will not be able to enroll in a health insurance plan in 2016, unless you qualify for a special enrollment period. A “Special Enrollment Period” is allowed when a life event occurs. For example: having a baby, getting married, or loss of employment.
- November 1, 2015: Open Enrollment started — first day you can enroll in a 2016 insurance plan through the Health Insurance Marketplace. Coverage can start as soon as January 1, 2016.
- December 15, 2015: Last day to enroll in or change plans for new coverage to start January 1, 2016
- January 1, 2016: 2016 coverage starts for those who enroll or change plans by December 15.
- January 15, 2016: Last day to enroll in or change plans for new coverage to start February 1, 2016
- January 31, 2016: 2016 Open Enrollment ends. Enrollment or changes between January 16 and January 31 take effect March 1, 2016.
- Before applying for an insurance plan, see if you qualify for a savings based upon your income. You will more than likely be asked this information prior to choosing a plan with your insurance carrier, before receiving a price quote. Note: your income will be verified through prior tax returns filed.
- All insurance carriers right now are in the open enrollment period: BlueCross - Blue Shield, Aetna, Cigna, Humana, and United Healthcare.
- Medicaid can be applied for at any time and does not have an open enrollment time period.
- Here are some helpful websites when comparing cost associated with insurance plans.
https://www.ehealthinsurance.com/
http://www.unitedhealthgroup.com
http://autoclubsouth.aaa.com/ - Offers health insurance quotes to AAA members. Through AAA representatives.
Hope this information helps in your quest to find the best health insurance coverage for 2016!
~Now Let’s Get Going ~ Sally Cares Team
Ref: www.Healthcare.gov
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In this section of Sallycares.com we focus on the changes that are happening with insurance coverage and provide you with information about those changes as we are made aware of them.
Whether it is Medicare, Medicaid or Commercial insurance, we are all noticing changes that are affecting our policies and coverage.
For Sallycares.com members we are more than happy to follow up on any specific insurance question that you may have regarding your insurance changes, but we are not able to suggest another insurance company and guarantee that you would not potentially have another issue. Your insurance agent should have the best information for you, since they would have knowledge of your health history and any specific needs you might have.
Commercial Insurance: There are many types of commercial insurance policies. They vary associated with the amount of deductible that is charged, as well as the type of coverage they provide. Usually, the higher the deductible, the lower the monthly premium. With the initiation of “Obama Care” there are anticipated changes that will be coming, but we are not exactly sure how the changes will roll out. Stay tuned as we learn more.
Medicare and Medicaid: Both of these programs are changing and the rules associated with how coverage will be altered are not yet clear. The newest update that we have received has been associated with Medicare’s changes regarding the provision of Durable Medical Equipment or DME. There is additional information regarding that change on the web site. The most important thing to know is that all prescribed equipment will now be provided by a supplier that won a “bid” for a specific zip code or geographical area. Example: If you are in Florida for the winter and need a wheelchair, the providers that are treating you in Florida are responsible to determine your zip code from your actual county of residence up north. Your state of residence zip code is where your equipment will need to be provided from. So that means that your wheelchair will need to be shipped from whichever supplier that is the area Medicare provider up north, to Florida. I know that the process sounds more complicated than what you are used to, and it is.
These are uncertain times regarding our healthcare. We all need to be our best advocate, and learn how to do that. Join Sallycares.com today and have support while we unravel all of these insurance issues together. As a member you can always send us your questions through “Contact Us,” and we will be glad to review your concerns!
“Now, let’s get going!” J Sally
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