Tuesday, January 15, 2013
Attention Qualified Medicare Beneficiaries (QMBs) – Increased Access to Care Beginning January 1, 2013
As many QMBs and Medicare counselors know, it can be difficult for QMBs to get access to physician care as in most states the Medicaid state agency (which runs the QMB program) will pay a physician (or other practitioner) only the difference between what Medicare pays for a service and what Medicaid would pay for the same service. In many cases, this is nothing, and, coupled with the fact that a physician or practitioner cannot balance bill a QMB, they often refuse to see one of these beneficiaries, as they believe their reimbursement is insufficient.
However, beginning January 1, 2013, a provision of the Affordable Care Act requires states to pay primary care physicians and practitioners at full Medicare rates. And among other things, this means that for QMBs, state agencies must pay the full difference between what Medicare allows and the (usual) 80% that it actually pays. So it well may be that your doctor or practitioner will now see you, as they will get reimbursed for their care for you at what they would for any other Medicare beneficiary (presuming they take assignment, of course). There is a catch, and it is that this provision in the law speaks only to those practicing family medicine, general internal medicine, and pediatric medicine, so you are not covered by this if you see a specialist. But it will quite possibly apply to someone you do go to seek care from, and you can bring this provision up when you try to make an appointment with a primary care physician or practitioner.
Tuesday, January 8, 2013
Renewal of the Outpatient Therapy Exceptions Process and of the Prepayment Review of and Preapproval Process for “Over-Limit” Outpatient Therapy Services
The just-signed American Taxpayer Relief Act of 2012 has several important provisions regarding outpatient therapy. Currently there is a statutory limit, or cap, on the dollar amount of outpatient therapy services a beneficiary can receive in a year. This limit has been in place for some years, and although the dollar amount changes each year, in 2013 the limit is $1,900 for physical and speech therapy combined, and a separate limit of $1,900 for occupational therapy. But for several years Congress has allowed exceptions to these limits, by permitting therapists, when these caps are exceeded, to certify that the additional, over-limit therapy services they are providing are medically necessary for the beneficiary. This act renews this exceptions process for all of 2013.
It also requires that, as in 2012, these therapies received in a hospital outpatient department be counted toward these caps, and imposes a new requirement that therapies received in the outpatient department of a critical access hospital also be included (these types of hospitals are often in rural areas).
And the law also renewed a requirement that outpatient therapy claims get special reviews. So if you have outpatient physical, speech language, and / or occupational therapy services covered by Medicare this calendar year, and Medicare has approved $3,700 or more for your therapy, you may get a notice from Medicare telling you that limits or caps are bring imposed on your outpatient therapy for the remainder of the year. (You may get this even if you are no longer actually getting therapy.)
What’s this all about?
Beneficiaries who are or will be receiving outpatient physical, speech language, and / or occupational therapy in 2013 need to be aware that the law requires Medicare Administrative Contractors (MACs), which are the companies that Centers for Medicare & Medicaid Services contracts with to review and process Medicare claims, to individually review all therapy claims that exceed a limit of $3,700 for a beneficiary. This limit is, as are the statutory limits, imposed on physical and speech therapy services combined, and, separately, on occupational therapy. So there are two, separate $3,700 thresholds. In addition, it requires that the review must be made before the Medicare Administrative Contractor processes and pays the claim.
Because these reviews would hold up payments of appropriate claims, the Centers for Medicare & Medicaid Services is also permitting therapy providers to request, from the Medicare Administrative Contractors, preapproval of any therapy services they render to a beneficiary. In this way, when they have actually performed the therapy and submit a claim, the medical necessity of the services had already been approved, and the claim can go right to payment. And rather than preapprove each and every therapy session, therapists must request the preapproval of blocks or chunks of 20 therapy days at a time.
This should concern beneficiaries, but only to a limited extent. These limits do not apply to beneficiaries in Medicare Advantage (Part C), but only to those in Original (fee-for-service) Medicare. And they are only for outpatient therapy, not for therapy you may get in as an inpatient during a Medicare covered hospital or Skilled Nursing Facility (SNF) stay. Nor does it apply to therapy you get under a home health plan of care.
But if these exceptions don’t apply, and you have gotten a lot of therapy this calendar year, you may get a voluntary Advance Beneficiary Notice (ABN) from your therapy provider that your services may not be covered. And whether you get one or not, beneficiaries need to understand that Centers for Medicare & Medicaid Services is taking the position that if you receive therapy over and above the statutory $1,900 limit and it is not medically necessary, you are not protected by the limitation-of-liability provision as the care is statutorily excluded, like eyeglasses or dental care. Normally, if a beneficiary gets a service that is not medically necessary, even when Medicare denies the claim, the beneficiary does not have to pay the provider for the care as it is assumed the beneficiary had no way of knowing that the care was not covered, unless of course they got an Advanced Beneficiary Notice saying that it wasn’t. So that’s why you may get one from your therapist, even if in this case they are not required to give it to you. But if you do get one, or if you think your therapy may exceed the $3,700 cap, you may wish to defer your therapy and ask that your therapist get preapproval from Medicare for your therapy. The Medicare Administrative Contractors have to OK or deny a preapproval request in 10 working days, or it is automatically approved, so the decision should not be too long in coming, and you may prefer waiting a bit to make sure whether or not you’ll be liable for the therapy services. And if it does deny the preapproval request, you may appeal its denial using the usual appeals process. (This is an exception to the usual rule that an appeal can be made only after a service has been given and the Medicare claim denied.)
It also requires that, as in 2012, these therapies received in a hospital outpatient department be counted toward these caps, and imposes a new requirement that therapies received in the outpatient department of a critical access hospital also be included (these types of hospitals are often in rural areas).
And the law also renewed a requirement that outpatient therapy claims get special reviews. So if you have outpatient physical, speech language, and / or occupational therapy services covered by Medicare this calendar year, and Medicare has approved $3,700 or more for your therapy, you may get a notice from Medicare telling you that limits or caps are bring imposed on your outpatient therapy for the remainder of the year. (You may get this even if you are no longer actually getting therapy.)
What’s this all about?
Beneficiaries who are or will be receiving outpatient physical, speech language, and / or occupational therapy in 2013 need to be aware that the law requires Medicare Administrative Contractors (MACs), which are the companies that Centers for Medicare & Medicaid Services contracts with to review and process Medicare claims, to individually review all therapy claims that exceed a limit of $3,700 for a beneficiary. This limit is, as are the statutory limits, imposed on physical and speech therapy services combined, and, separately, on occupational therapy. So there are two, separate $3,700 thresholds. In addition, it requires that the review must be made before the Medicare Administrative Contractor processes and pays the claim.
Because these reviews would hold up payments of appropriate claims, the Centers for Medicare & Medicaid Services is also permitting therapy providers to request, from the Medicare Administrative Contractors, preapproval of any therapy services they render to a beneficiary. In this way, when they have actually performed the therapy and submit a claim, the medical necessity of the services had already been approved, and the claim can go right to payment. And rather than preapprove each and every therapy session, therapists must request the preapproval of blocks or chunks of 20 therapy days at a time.
This should concern beneficiaries, but only to a limited extent. These limits do not apply to beneficiaries in Medicare Advantage (Part C), but only to those in Original (fee-for-service) Medicare. And they are only for outpatient therapy, not for therapy you may get in as an inpatient during a Medicare covered hospital or Skilled Nursing Facility (SNF) stay. Nor does it apply to therapy you get under a home health plan of care.
But if these exceptions don’t apply, and you have gotten a lot of therapy this calendar year, you may get a voluntary Advance Beneficiary Notice (ABN) from your therapy provider that your services may not be covered. And whether you get one or not, beneficiaries need to understand that Centers for Medicare & Medicaid Services is taking the position that if you receive therapy over and above the statutory $1,900 limit and it is not medically necessary, you are not protected by the limitation-of-liability provision as the care is statutorily excluded, like eyeglasses or dental care. Normally, if a beneficiary gets a service that is not medically necessary, even when Medicare denies the claim, the beneficiary does not have to pay the provider for the care as it is assumed the beneficiary had no way of knowing that the care was not covered, unless of course they got an Advanced Beneficiary Notice saying that it wasn’t. So that’s why you may get one from your therapist, even if in this case they are not required to give it to you. But if you do get one, or if you think your therapy may exceed the $3,700 cap, you may wish to defer your therapy and ask that your therapist get preapproval from Medicare for your therapy. The Medicare Administrative Contractors have to OK or deny a preapproval request in 10 working days, or it is automatically approved, so the decision should not be too long in coming, and you may prefer waiting a bit to make sure whether or not you’ll be liable for the therapy services. And if it does deny the preapproval request, you may appeal its denial using the usual appeals process. (This is an exception to the usual rule that an appeal can be made only after a service has been given and the Medicare claim denied.)
Sunday, November 25, 2012
Changes in Medicare Premiums, Deductibles, etc., in 2013
Most of the Medicare annual change amounts have been released for 2013, and the good news is that although beneficiaries will be seeing some increases in their premiums, deductibles, etc., these are, on the whole, rather modest.
The Part B deductible for 2013 will be $147, up $7 from $140. This is a small increase to those of you who don’t have a Medigap policy, or whose policy doesn’t pay your Part B deductible.
Because there was a Social Security cost-of-living increase (of 1.7%), Medicare Part B monthly premiums were again permitted to rise, and the standard premium you will pay is $104.90, up $5.
For those of you who have to pay the High Income Part B Premium Surcharge, your monthly surcharge will increase from $2 to $11 per month, depending on your income level. And also remember that your 2013 surcharge will be based on your 2011 income, and this may put you in a higher or lower surcharge bracket, or may put you into or out of having to pay a surcharge.
And the Part B coinsurance rate for outpatient mental health services will decrease from 40% in 2012 to 35% in 2013. (And next year, 2014, it will lower to 20%, the general Part B coinsurance rate, so there will no longer be any disparity.)
The Part A inpatient hospital deductible goes up by $28 in 2013 to $1,184. This is the amount you are responsible for the first 60 days of an inpatient stay. And, of course, the various co-pays for longer hospital stays, and for skilled nursing facility (SNF) stays beyond 20 days, are also affected by this change, but these are modest.
Those relatively few of beneficiaries who pay for Part A will welcome the news that their premiums will actually decrease. The Part A premium for those currently paying $451 a month will decrease $10 a month to $441, and for those paying $248, it will go down $5 to $243 a month.
The Centers for Medicare & Medicaid Services reports that in Part C – Medicare Advantage or Medicare managed care – the premiums have gone down by 7%, on average, for 2013. But always remember that you need to do your homework every year to see if you are in the best plan for you. And also remember that you mostly have only until December 7 to do this, that is, the Annual Election Period or Open Enrollment lasts only until that date. Several exceptions exist to this deadline. One is that if your plan is leaving the Medicare program, you have until February 28. Another is that, if there is a plan with a five-star quality rating where you live (and there may not be one where you are), you can switch to it after Open Enrollment and in any month in 2013 (except December). And this is new in 2013; to facilitate beneficiary enrollment into higher quality plans, a special enrollment period (SEP) will be given to beneficiaries who are enrolled in “low performing” Medicare Advantage and Part D drug plans. By “low performing” is meant any plan which has had an overall star rating of less than three stars for three years in a row. The Centers for Medicare & Medicaid Services (CMS) will send notices to individuals enrolled in these plans informing them of their plan’s low rating and offering them an opportunity to request a special enrollment period to move into a higher quality plan for 2013. They can do this any time after the Open Enrollment and in any month in 2013 (except December). And, finally, if you have been affected by Hurricane Sandy, you can call 1-800-MEDICARE to ask for an extension of the December 7 deadline.
For Part D, again changes are minimal from 2012, but the overall recommended structure has changed some. The deductible is up $5 to $325, but remember that many plans have none or a smaller deductible than this. The next payment band, the 25% Coinsurance Band, covers the next $2,645 of your drugs, and you pay 25% of this, or $661.25, while your plan covers $1,983.75. Your plan may structure this differently. In the “donut hole,” in 2013 you will have to pay only 47.5% of the cost of your brand name drugs, slightly less than the 50% you did in 2012, as manufactures will give a 52.5% discount. And now the government will pay 21% of the cost of your generics, up from 14% in 2012. And, finally, in the Catastrophic (or 5% Insurance) Band, which starts when your drug “expenses” reach $4,750, you will pay a minimum of $2.65 for a generic or $6.60 for a brand name drug, but no more that 5% of its cost, if that is greater than these amounts. (And by “expenses” is meant your deductible, anything you spent in the 25% band and in the donut hole, AND the 52.5% that manufacturers discount on your brand name drugs in the donut hole (but not the 21% the government pays on your generics).
The structure for “Extra Help” or “Low Income Subsidy” beneficiaries is, of course, different, but the increases these beneficiaries will experience are nil to minimal.
And on the whole Part D premiums have increased by only a hair for 2012. But the admonition above with regard to Medicare Advantage plans applies here also – do your homework to make sure you are in the best Part D prescription drug plan for 2013. And the special enrollment periods discussed above (Non-Renewing plans, the 5-Star Quality Rating, Low-Performing plans and Hurricane Sandy) all apply to Part D Plans also.
nd there is good news for those of you who have to pay the High Income Part D Premium Surcharge. Your monthly surcharge will either not increase, or will increase by only 20¢ a month. But remember, as with the High Income Part B Premium Surcharge, your surcharge will be based on your 2011 income, and this may put you into a higher or lower bracket or may put you into or out of having to pay a surcharge.
Medicare Premiums, Deductibles, etc., in 2013
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