Medicare coverage is changing at PAHCS

This article submitted by Linda Stelling on 9/1/98.

New federal regulations went into effect July 1 which will change the way Medicare reimburses hospitals, nursing homes, and individuals.

ďThe federal government is trying to decrease their costs,Ē Bev Mueller, PAHCS assistant administrator, said.

ďTwo changes went into effect that many people arenít aware exist. The medicare changes are coverage for skilled nursing home and outpatient therapy. Part A Medicare covers inpatient hospital stay and skilled care in a nursing home. Part B medicare covers doctorís visits and outpatient services at a hospital or clinic,Ē Mueller said.

A person on medicare, hospitalized three or more days, (needs to be part ďAĒ billing) may receive reimbursement for the first 100 days in a skilled care nursing home which is defined as a place providing care by licensed nurses or therapists.

If that same patient is treated as an outpatient, (part ďBĒ billing) there is a $1,500 per year cap on therapy coverage. A patient receiving physical therapy and speech therapy has a maximum limit of $1,500. Occupational therapy has another $1,500 per year cap. The physical and speech therapy are not separated under the new rules. Any charges above and beyond that are the patientís responsibility.

ďIt doesnít make any difference if the therapy was started in Minneapolis or at Rochester and finished here, the total amount which medicare will cover is $1,500,Ē Mueller stressed.

Under the old reimbursement program, 80 percent of the bill was covered by Medicare and 20 percent co-insurance carrier. The coverage was unlimited as long as the therapy was medically justified and provided in a hospital/ nursing home facility.

ďPeople were lucky the new system is in effect only six months this year. Next year it will affect patients harder since it is a 12-month period,Ē Mueller said.

ďPeople need to be aware how much their therapy bills are as everything above the $1,500 is out of their pocket and wonít be covered,Ē she added. This change isnít just for Minnesotans, but nationally set by the federal government.

Mueller said the average rate for therapy ranges anywhere from $75 to $100 per visit.

Another area of change is care for a person on insulin. If a person receives an insulin injection daily for 14 days, and has two dose changes, they are covered. If they are on an established insulin dose, they are not covered.

ďThere are seven categories sub-divided into 44 different payment levels to determine who is or isnít reimbursed for care,Ē Mueller said. ďThe new ruling will create increased paper work for everyone concerned, the health care provider as well as the insurance companies.Ē

Mueller stressed the biggest thing people need to be aware of is that care they were covered for prior to Oct. 1 may not be covered after that date. The new prospective payment system for nursing home care wonít go into effect at the Paynesville Area Health Care System until Oct. 1, when they start their new fiscal year.

ďEach resident will be evaluated at the time of treatment and made aware of the new changes,Ē Mueller said. ďI can foresee many hardships and reimburse-ment becoming more restrictive.Ē

Mueller stressed that people on medicare need to check their coverage and options available as to what types of therapy are covered. In many instances, nursing home therapy will be covered and not affect the out-patient therapy amount.
ďLocally, we have no local control over this. People who are dissatisfied with the new federal rulings should write their state and federal legislators to express their views,Ē she added.

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