How to Get the Rehab Therapy You Need

Have you been denied rehabilitation therapy because your medical condition was no longer improving?  

In the past, in order for Medicare to pay for occupational therapy (OT), physical therapy (PT) and speech-language therapy (SLP) services, Medicare required that these services help you to improve or regain your ability to perform these functions. If your progress slowed down too much or stopped, then Medicare would no longer cover its share of the cost. If you simply wanted to continue therapy for maintenance of your condition, you would be responsible for the full cost of therapy.

The problem with this is that the law did not require a person’s condition to improve in order for Medicare to pay for rehabilitation therapy. People were being denied the coverage that they were entitled to receive.

A legal agreement, Jimmo v Sebelius, settled this and determined that Medicare is required to cover the costs of rehabilitation therapy for qualified individuals who receive therapy for maintenance of their condition. The agreement applies to skilled maintenance services provided in all three care settings including Medicare home health, outpatient therapy and skilled nursing facility benefits and applies equally to Medicare Advantage as to the traditional Medicare program.

Specific language in the agreement states that “Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.” The agreement is intended to clarify that when skilled services are required to provide care that is reasonable and necessary to prevent or slow further deterioration; coverage cannot be denied based on the absence of potential for improvement or restoration.

Medicare has not expanded coverage. They are providing coverage in situations where they should have been provided in the first place.

Patients must still meet certain requirements for any treatment to be covered, including:
- Medically necessary
- Appropriate and effective in treating the condition
- Provided by a skilled professional
- Reasonable in terms of frequency and duration.

The payment limits, called “therapy caps,” are still in effect as well.

The bottom line is that not all medical providers are aware of these Medicare coverage changes and you may still be denied coverage for rehabilitation therapy you need. You need to be aware of these changes and bring them to the attention of your provider. If you’re still being denied the rehab therapy you are entitled to, you or your doctor will need to contact Medicare to correct the claim.

Who will shoulder your retirement health care costs?

If you’re planning on your employer picking up the cost of your healthcare once you retire, you may want to rethink your plans. The number of employers who provide health benefits has declined from 40% to 28% between 1988 and 2013. Today, less than one in five people work for a company that offers health benefits for their retirees.

The problem boils down to cost. Healthcare costs continue to grow and retirees are living longer. We are seeing more and more companies taking steps to contain costs by capping their contributions, tightening eligibility standards and eliminating new employees from this benefit.
The picture has improved for early retirees. They are enjoying the benefits of the Affordable Care Act and the availability of insurance on the healthcare marketplace. In the past, retirees who were too young to qualify for Medicare struggled to fill the gap in coverage until they turned 65. They were often denied coverage for pre-existing conditions or had to bear the burden of expensive premiums.

For retirees over age 65, the gap in covered medical costs is widening. Medicare alone does not cover 100% of medical costs and excludes long-term healthcare and dental care. In place of employee provided retiree health benefits, Medicare beneficiaries are increasingly relying on supplemental Medicare coverage such Medigap or Medicare Advantage Plans.

As employers move away from retiree health coverage, it's important for workers today to prepare themselves for future healthcare expenses and consider supplemental insurance plans. It is estimated that a 65-year-old couple who retired in 2013 will spend $220,000 on healthcare over the course of retirement.

And more than 70% of seniors will eventually need some sort of long-term healthcare, which is not covered by Medicare. Pre-retirees might want to consider long-term care insurance before they leave the workforce. The average policy costs about $3,000 a year — not cheap but certainly less expensive than the average of more than $83,000 a year that you’d shell out for a private nursing home stay without insurance.

If you are concerned about who will shoulder your health care costs, call me and we'll work together to put together a plan for you.

Fun Facts to brighten your day

Did you know . . .

• On average, women say 7,000 words per day. Men speak just over 2,000

• Americans eat 18% more vegetables today than they did in 1970.

• The width of your arm span stretched out is equal to the length of your whole body.

• Research shows that people will walk 30% longer if they listen to music when they walk.

• Laughing lowers levels of stress hormones and strengthens the immune system.

Do Marketplace Insurance Plans cover mental health and substance abuse services?

Yes.

All Marketplace insurance plans cover mental health and substance abuse services as an essential health benefit.

Health insurance plans available in the Marketplace must cover ten categories of essential health benefits. One of these categories is mental health and substance abuse services, also known as substance use disorder.

These services include behavioral health treatment, such as psychotherapy and counseling. They also include mental and behavioral health inpatient services and substance use disorder treatment.

Mental and behavioral health and pre-existing conditions

Marketplace plans can’t deny you coverage or charge you more just because you have a pre-existing condition. This includes mental health and substance use disorder conditions.
Coverage for treatment of pre-existing conditions begins as soon as your Marketplace coverage is in effect. There’s no waiting period for coverage of these services.

There are also no lifetime or yearly dollar limits for mental health services. Marketplace plans can’t apply yearly or lifetime dollar limits on coverage of essential health benefits which includes benefits for mental health and substance use disorder services.

Parity protections for mental health services

Marketplace plans must provide certain “parity” protections between mental health and substance abuse benefits on the one hand, and medical and surgical benefits on the other.This means that in general, limits applied to mental health and substance abuse services can’t be more restrictive than limits applied to medical and surgical services. The kinds of limits covered by the parity protections include:
· Financial, like deductibles, copayments, coinsurance, and out-of-pocket limits
· Treatment, like limits to the number of days or visits covered
· Care management, like being required to get authorization of treatment before getting it

(taken from HealthCare.gov)

Ohio Celtic Fest is this weekend

If you're looking for something fun to do this weekend, visit 
The Ohio Celtic Fest at the Lake County Fairgrounds, on Mentor Avenue in Painesville Township.  There'll be six stages of non-stop musical entertainment - from Celtic rock to ballads and everything in between. Bagpipe band. Irish dancers from four local schools of dance. Lots of food. Shopping. And a kid's area with magicians, storytellers, petting zoo and bouncy things.

Stop by the Coffee House, sponsored by Mutsko Insurance Services, if you get a chance.

For more information, go to ohiocelticfest.com

Four ways to save big on prescription costs

1. Shop Around.
Prices at different pharmacies can vary dramatically, as much as from $4 to $250 or more within your neighborhood for the same prescription. Visit www.goodrx.com to compare prices and find coupons.  It pays to check.

Be sure to ask for the pharmacy’s lowest price because additional discounts may be available when you’re a member of a store’s loyalty plan. And don’t overlook your insurer’s “preferred” retail or mail order pharmacy when comparing costs. Some insurers and Medicare Part D Plans have negotiated deep-discounts to help you save.

2. Be wary of coupons.
Makers of brand-name drugs often flood the market with discount coupons in order to keep you as a customer. Even if a coupon cuts the cost you pay at the counter, your employer and insurance company are often paying the full price which will cost you in higher premiums down the road.

3. Cut the quantity 
Ask for a 14-day supply to get you started and see whether it help you without side effects. Once you're sure it works for you, you can refill a larger quantity.

4. Ask about OTC drugs, samples or a two week supply
Your physician may write prescriptions for drugs even after they are available over-the-counter. But, over the counter drugs are often cheaper so be sure to ask your doctor if your drug is available over the counter. 

What your doctor calls your visit can cost you.

Annual Wellness or Preventive Care Visit?

How your visit is coded by your physician’s office may mean the difference between your claim being covered or denied.

 

If you have Medicare Part B for longer than 12 months, you can get an annual wellness visit or update a personalized prevention plan on your current health and risk factors. 

This visit is covered once every 12 months.

 

Be sure your doctor codes it as an Annual Wellness Visit not a preventive visit to avoid any mix-ups or your claim being denied.