News and FAQs

 

 

NEWS

2019 Medicare Part A and Part B Coinsurance and Deductibles

 

Medicare Part A- Inpatient Skilled Nursing Facility stay

Beneficiary pays:

Coinsurance for days 21-100 (of each benefit period)

CY 2019-  $170.50

 

Medicare Part B – Therapy services in a SNF

Deductible

CY 2019 – $185.00

 

 

2018 Medicare Part A and Part B Coinsurance and Deductibles

 

Medicare Part A- Inpatient Skilled Nursing Facility stay

Beneficiary pays:

Coinsurance for days 21-100 (of each benefit period)

CY 2015 – $157.50

CY 2016 – $161.00

CY 2017 – $164.50

CY 2018 – $167.50

 

Medicare Part B – Therapy services in a SNF

Deductible

CY 2015 – $147.00

CY 2016 – $166.00

CY 2017 – $183.00

CY 2018 – $183.00

 

2017 Medicare Part A and Part B Coinsurance and Deductibles

 

Medicare Part A- Inpatient Skilled Nursing Facility stay

Beneficiary pays:

Coinsurance for days 21-100 (of each benefit period)

CY 2015 – $157.50

CY 2016 – $161.00

CY 2017 – $164.50

 

Medicare Part B – Therapy services in a SNF

Deductible

CY 2015 – $147.00

CY 2016 – $166.00

CY 2017 – $183.00

 

CMS Publishes 2016 Medicare Parts A & B Premiums and Deductibles

 

Medicare Part A- Inpatient Skilled Nursing Facility stay

Beneficiary pays:

Coinsurance for days 21-100 (of each benefit period)

CY 2015 – $157.50

CY 2016 – $161.00

 

Medicare Part B – Therapy services in a SNF

Deductible

CY 2015 – $147.00

CY 2016 – $166.00

 

Integral Quality Care (Integral) Medicaid changes effective November 1, 2015

Effective 11/1/15 Molina Healthcare of Florida, Inc. (Molina) purchased Integrals’s Medicaid line of business. The Agency for Health Care Administration (ACHA) will transition Integral’s Medicaid membership to Molina effective 11/1/15.

Molina will be issuing new Member ID cards. All billing and claims reimbursement will be provided by Molina for dates of service beginning November 1, 2015. All claims for service dates prior to November 1, 2015, must continue to be submitted through Integral and related questions may be directed to Integral’s provider services at 1-866-258-4326.

Questions related to this transition may be directed as follows:

Molina Member Services: 866-472-4585

Molina Provider Services: 855-322-4076

Website: www.molinahealthcare.com

 

MedPac considers eliminating observation stays

Observation status is not working as a way of classifying hospital patients and should be eliminated, members of the Medicare Payment Advisory Commission proposed at a Nov. 6 meeting.

The increasing prevalence of hospital observation stays has been of sharp concern to post-acute providers. Under current rules, Medicare only will cover skilled nursing services after a beneficiary spends three days as a hospital inpatient, and time spent in observation is not counted toward this threshold. About 11,000 hospital stays ended with a non-covered discharge to a skilled nursing facility in 2012, staffers told MedPAC members during a presentation last Thursday.

Eliminating observation stays would resolve such systemic problems, said commission member Craig Samitt, M.D., MBA, chief executive officer of medical group HealthCare Partners. The idea also was put forward by Cori Uccello of the American Academy of Actuaries, and it won limited support from outgoing chairman Glenn Hackbarth, Bloomberg BNA reported.

However, other commissioners said making observation stays into inpatient stays could wreak havoc with billing procedures and increase costs for beneficiaries, according to BNA.

Other potential remedies for the surge in observation stays were suggested. One was to have Recovery Audit Contractors focus their oversight more strictly on hospitals that have a high percentage of one-day inpatient stays. RACs have been very aggressive in challenging inpatient determinations, which could be leading hospitals to put more people in the observation category.

Changing the three-day requirement for skilled nursing coverage also came up, BNA reported. In the past, Hackbarth has come out in support of this, calling the current rule “archaic”.

Eliminating the three-day rule could increase Medicare spending by widening post-acute coverage. To offset this spending, Medicare might have to reduce SNF payments, the MedPAC staffers noted. Offsets also could come from penalties on facilities that inappropriately re-certify long-term residents.

 

2015 Medicare Open Enrollment Begins 10/15/14

There are an average of 29 drug plans to digest, and about 18 options for Medicare Advantage, the plans delivered through private insurers.  Then there are the 10 supplemental plans that cover what traditional Medicare does not.  The Medicare open enrollment season runs from October 15th through December 7th, 2014.

Here is a quick primer on original Medicare:  Part A covers hospital and skilled nursing facility stays, as well as some home health visits and hospice care.  Part B covers preventive care, doctor visits and outpatient services.  Premiums, for  most retirees, were $104.90 a month last year and are projected to be the same in 2015.

Deductibles, co-payments and coinsurance (that is when you pay for percentage of medical services) can be burdensome since there is no out-of-pocket ceiling.  That is one of the reasons most people buy supplemental coverage, known as Medigap, to cover out-of-pocket costs on Parts A and B.  People with retiree employer coverage rely on that instead of a Medigap plan.

Medicare Part D, which is offered only through private insurers, covers drugs.  The average monthly premium for such plans is estimated at $32 in 2015, according to the Centers for Medicare and Medicaid Services.

Alternatively, you can just buy a Medicare Advantage plan from a private insurer, also referred to as Part C.  It can serve as a one-stop shop because it covers Parts A, B and often a drug plan – and sometimes throws in extras like dental and vision coverage.  Average monthly premiums for Advantage plans are estimated to rise to $33.90, a $2.94 increase, in 2015, according to the Centers for Medicare and Medicaid Services. (You pay that in addition to the Part B premium).

Some consumer advocates favor using traditional Medicare with a supplemental plan, largely because it is more predictable and you are free to see any doctor who accepts Medicare.

Medigap, with 10 plan levels that are labeled with letters from A to N, is federally standardized coverage, which means coverage must be exactly the same across insurers.   For instance, the option known as Plan F will pay for your Part A and Part B deductibles.  “This is one area, once you decide on the level of coverage you want, where you can go for the lowest price because you know Plan F will be exactly like any other Plan F,” said Jocelyne Watrous, advocate for the Center for Medicare Advocacy.

Depending on the plan, the total cost of your premiums could come close to your final out-of-pocket cost for the year.  In Connecticut, for instance, one of the most comprehensive Medigap policies is called Plan F.  It costs an individual about $218 a month, or $2,622 annually.

If you are contemplating switching from Medicare Advantage back to original Medicare – and you want to buy a supplemental policy -that is something you may want to do while you are younger and healthier.  Later on, coverage may become more expensive or you can be denied altogether.  With some exceptions, individuals are guaranteed coverage only if they buy it during a special period six months after their 65th birthday.  During that time, insurers cannot refuse to sell you a policy because of a pre-existing condition or other medical issue, nor can they charge you more.

Outside of that safe period, you aren’t guaranteed coverage under federal law, though many states including New York, extend greater protections.  It is important to ask your local State Health Insurance Assistance Program, or SHIP agency, for more details.  After you buy a Medigap policy, it generally cannot be canceled because you are old or sick.

Nearly 16 million people, or 30 percent of all Medicare beneficiaries, enroll in a Medicare Advantage plan.  Most people are attracted by the plans’ enticingly low and sometimes zero premiums and, for certain services, low co-payments.  Some even offer limited dental or vision coverage, advocates said.

The drawback of Advantage plans are their limited networks of providers.  Doctors can drop out midyear.  And consumers are responsible for all cost-sharing, which can be unpredictable.  Those are capped at an out-of-pocket limit for in-network services of $6,700 in 2015, although the Center for Medicare and Medicaid Services recommends a limit of $3,400.

But it is difficult to calculate how fast you might reach those ceilings.  “The cost-sharing requirements are harder to compare…hard to anticipate what their health care needs might be,” said Tricia Neuman, director at Kaiser. “…consider what services you would need if you were sick and take a careful look at potential costs under various plans.”

People who travel frequently or spend a time in another state also need to ensure that they will be covered.  “Snowbirds need to consider whether the networks and coverage extends to two places,” said Nicole Duritz, vice president at AARP.

If you are already enrolled, the “annual notice of change” sent to plan enrollees will detail changes in coverage, costs and networks.  But if you are dissatisfied with your Advantage plan for any reason, you can un-enroll from January 1 to February 14 and switch to original Medicare.

Even if you are happy with your Part D coverage, don’t assume it will remain exactly the same. Lists of covered drugs often change or the company may insert new restrictions, limiting quantities or requiring you to try  another drug first.

Go to the Medicare website’s Plan Finder, where you can enter your drugs, the dosage and frequency, as well as where you like to buy them.  It will then show you what the plans cover and your total estimated costs for the year.  “The plans are complicated…so much variation…the only way to compare…use Plan Finder,” Ms. Watrous said.

Don’t shop on price alone, said Mr. Baker, who advised calling the plan, or even your doctor or pharmacist, who has a lot of interaction with the different plans.

Besides local SHIP agencies, advocates suggest that people check out the latest Medicare and You booklet, which all 54 million enrollees should have received in the mail by now.  It’s remarkably clear.  To talk to someone live, call 1-800-Medicare.

References: http://www.nytimes.com/2014/10/04/your-money/beware-of-shifting-options-within-medicare-plans.html?emc=edit_th_20141004&nl=todaysheadlines&nlid=31644801

 

Implementation of FY 2015 SNF PPS MDS 3.0 Policy Changes Effective October 1, 2014

For the reasons specified in the FY 2015 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule and FY 2015 SNF PPS Proposed Rule; Providers are permitted, in certain circumstances, to complete a Change of Therapy (COT) Other Medicare Required Assessment (OMRA) for a resident who is not currently classified into a Resource Utilization Group, Version 4 (RUG-IV) therapy group, or receiving a level of therapy sufficient for classification into a RUG-IV therapy group. These circumstances are limited to cases in which the resident had qualified for a RUG-IV therapy group on a prior assessment during the resident’s current Medicare Part A stay and had no discontinuation of therapy services between day 1 of the COT observation period for the COT OMRA that classified the resident into his/her current non-therapy RUG-IV group and the Assessment Reference Date (ARD) of the COT OMRA that reclassified the resident into a RUG-IV therapy group.

The policy is effective October 1, 2014. More specifically, the COT OMRA which would be used to reclassify the resident into a RUG-IV therapy group from a RUG-IV non-therapy group, pursuant to the rules outline in the FY 2015 SNF final rule and in the MDS 3.0 manual, must have an ARD set for on or after October 1, 2014.

 

Billing Changes Effective July 1, 2013

As of July 1, 2013, all entities billing outpatient therapy services under Medicare Part B must begin or continue submitting functional limitation data (G-codes) for any beneficiary, or claims will be returned unpaid. The therapist’s projected goal for functional status at the end of the treatment will be reported on the claim form at every designated reporting interval. Modifiers will indicate the extent of the severity/complexity of the functional limitation.

Read More Here: http://www.apta.org/payment/medicare/codingbilling/functionallimitation/

 

Statewide Medicaid Managed Care Program:

The Florida Medicaid program is in the process of implementing a new system effecting Medicaid recipients receiving long-term care services. Individuals who are enrolled in the Long-term Care Diversion Program are required to participate; meaning that Medicaid recipients will start receiving their long-term care services through the new Statewide Medicaid Managed Care Long-term Care (LTC) program. Providers will need to contract with the offered Health Maintenance Organizations (HMOs) or Provider Service Networks (PSNs).

Between October 1, 2013, and September 30, 2014, each selected plan must offer a network contract to all nursing facilities, hospices and aging network service providers in their region. Nursing facilities, hospice providers or agencies that are enrolled Medicaid providers must participate in all eligible plans selected by the Agency for Health Care Administration (AHCA) in the region in which the provider is located.

Learn more here: http://www.flmedicaidmanagedcare.com/GeneralInfo.aspx

 

 

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FAQs

Question: What is the 2015 Medicare Part A copay amount for days 21-100?

Answer: $157.50 per day

 

Question: What is the 2015 annual Medicare Part B deductible?

Answer: $147.00 (unchanged from 2014)

 

Question: What is the 2015 Medicare Part B monthly premium?

Answer: $104.90, unchanged from 2014  (for most individuals, those with very high income levels will have a higher premium)

 

Question: What is the 2014 Medicare Part A copay amount for days 21-100?

Answer: $152.00 per day

 

Question: What is the 2014 annual Medicare Part B deductible?

Answer: $147.00

 

Question: What is the 2014 Medicare Part B monthly premium?

Answer: $104.90 (for most individuals, those with very high income levels will have a higher premium)

 

Question: What are the therapy caps for 2014?

Answer: $1,920 for PT/ST and $1,920 for OT

While the caps for 2015 are yet to be announced, probably due to the fact that the exception process is in effect until 3/31/15, if caps are announced or if the caps are finally repealed we will post it here.

 

Question: What about the $3,700 cap for automatic manual medical reviews?

Answer: For at least the first quarter of 2014 it should remain the same. Sometime in the first quarter Congress will make a more permanent decision regarding therapy caps and how they will be applied or if they will be removed entirely and replaced with medical reviews only at certain dollar levels or therapy usage levels. “On 12/18/13, Congress passed the Bipartisan Budget Act of 2013. Congress also included a three-month extension of the therapy caps exceptions process in the budget agreement. In years past, Congress has passed year-long extensions of the exceptions process. However, this year is different – for the first time, there is significant movement in Congress to remove the therapy caps altogether. There is currently a bill in the Senate that would repeal the therapy caps and replace them with a system that would allow for more targeted reviews of therapy use instead of the current arbitrary monetary caps. Because Congress did not have time to pass the repeal before the expiration of the exceptions process, they passed the three-month extension to allow for more time for agreement in the New Year.”   Quote courtesy of:

http://www.parkinsonsaction.org/news/congress-passes-budget-agreement-90-day-therapy-caps-exceptions-process-extension

 

Question: What is being used to replace speech therapy Current Procedural Terminology (CPT) Code 92506 (the speech evaluation code), which is no longer a valid code after 12/31/13?

Answer: Effective 1/1/14 there are four new CPT codes with more specific evaluation parameters. The fee schedule for these new codes is located in the 2014 Medicare Fee Schedule, which was published in November 2013. The four codes are:

92521    Evaluation of speech fluency (stuttering, cluttering)

92522    Evaluation of speech sound production (articulation, phonological process, apraxia, dysarthria)

92523    Evaluation of speech sound production; with evaluation of language comprehension and expression (receptive and expressive language)

92524    Behavioral and qualitative analysis of voice and resonance

 

Question: What happens to the 2% Medicare reimbursement cuts for providers?

Answer: The new Federal budget extends those cuts, at 2%, through 2023.