​On January 19, 2021, the Centers for Medicaid and Medicaid Services (CMS) issued a final rule addressing Medicare Part C – Medicare Advantage Plans and Part D Prescription Programs. The rule is complex, but here are some of the provisions that are particularly relevant.

The PAID Act recently became law. The act paves the way for Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) to receive valuable Medicare Part C and Part D plan information for the injured parties they submit through the Centers for Medicare and Medicaid Services’ (CMS’) Section 111 query process. Now that we are only ten short months away from implementation, many are asking: what are the practical implications of this change, and what should we do to prepare for December 2021?

What does the PAID Act do?

Approximately 50 million—or 20 percent—of American adults reported donating to a crowdfunding campaign to help raise money for a medical bill or treatment.
(CHICAGO, Feb. 19, 2020)

​One in five Americans reported that they or someone in their household have contributed to a crowdfunding campaign to pay for medical bills or treatments, according to a new AmeriSpeak® Spotlight on Health survey from NORC at the University of Chicago. Crowdfunding is the process by which individuals may raise funds from a large amount of people, often through sites such as GoFundMe.

3 trends behind the growth of house calls and medical care in stores
The Mall of America on the outskirts of the Twin Cities in Minneapolis has more than 520 stores and restaurants, plus an indoor theme park. Last November, it added something else, the Health Fairview Walk-In Clinic with five medical exam rooms, lab space for tests, a radiology room and pharmacy services. Anyone can stop in.
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The mall’s health clinic is part of an intriguing shift in how health care is getting delivered in the U.S. Other accelerating signs of change: more doctors and nurses making house calls; Walmart’s first health clinic attached to a Supercenter store; CVS Health’s strategy to offer a broad range of health services in its stores by expanding its HealthHUB and MinuteClinic format and Walgreen Boots Alliance transforming stores into neighborhood centers for older customers.

Among all the changes coming to Medicare Supplement plans and Medicare Part D, Medicare costs will also be changing in 2020. In 2020, the Medicare Part A premium will be $458, however, many people qualify for premium-free Medicare Part A. The Medicare Part B premium will increase to $144.60, and the Part B deductible will rise to $198 in 2020.

Why are Changes Coming to Medicare in 2020?

One of the things that concerns people most about nursing home care is how to pay for that care.  There are basically four ways that you can pay the cost of a nursing home:

1.  Long Term Care Insurance - If you are fortunate enough to have this type of coverage, it may go a long way toward paying the cost of the nursing home. Unfortunately, long term care insurance has only started to become popular in the last few years and most people facing a nursing home stay do not have this coverage.

2.  Pay With Your Own Funds - This is the method many people are required to use at first. Quite simply, it means paying for the cost of a nursing home out of your own pocket. Unfortunately, with nursing home bills averaging $10,000 to $12,000 per month, or more, in Washington, there are few people who can afford a long term stay in a nursing home.

3.  Medicare - This is the national health insurance program primarily for people 65 years of age and older, certain younger disabled people and people with kidney failure. Medicare provides short term assistance with nursing home costs, but only if you meet the strict qualification rules.

4.  Medicaid/COPES - This is a federal and state-funded and state administered medical benefit program which can pay for the cost of the nursing home if certain asset and income tests are met.

What About Medicare?
Medicare is the federally funded and state administered health insurance program primarily designed for individuals over age 65. There are some limited long-term care benefits that can be available under Medicare. In general, if you are enrolled in the traditional Medicare plan, and you’ve had a hospital stay of at least 3 days, and then you are admitted into a skilled nursing facility (often for rehabilitation or skilled nursing care), Medicare may pay for a while. (If you are a Medicare Managed Care Plan beneficiary, a 3-day hospital stay may not be required to qualify.)

If you qualify, traditional Medicare may pay the full cost of the nursing home stay for the first 20 days and can continue to pay for the next 80 days, but with a deductible that’s about $100 per day. Some Medicare supplement insurance policies will pay the cost of that deductible. For Medicare Managed Care Plan enrollees, there is no deductible for days 21 thru 100, if the strict qualifying rules continue to be met. So, in a best-case scenario, the traditional Medicare/Medicare Managed Care Plan may pay up to 100 days for each “spell of illness.” In order to qualify for this, “100 days of coverage,” however, the nursing home resident must be receiving daily “skilled care” and generally must continue to “improve.” (Note: Once the Medicare and Managed Care beneficiary has not received a Medicare covered level of care for 60 consecutive days, the beneficiary may again be eligible for the 100 days of skilled nursing coverage for the next spell of illness).

While it’s never possible to predict at the outset how long Medicare will cover the rehabilitation, from our experience, it usually falls far short of the 100-day maximum. Even if Medicare does cover the 100-day period, what then? What happens after the 100 days of coverage have been used?
At that point, in either case, you’re back to one of the other alternatives... long term care insurance, paying the bills with your own assets, or qualifying for Medicaid.

Contact us today to discuss your individual situation and to find out how Tacoma Elder Care can help you and your loved ones.