The Changing Landscape of Medicare for 2013 and Beyond

This is a guest post contributed by Shannon Martin, M.S.W., CMC is Director of Communications for Aging Wisely, LLC and EasyLiving, Inc

Medicare recipients will experience a variety of changes in 2013, as a result of healthcare reform measures, annual changes and various occurrences within the healthcare system.

The Affordable Care Act included a number of changes to the Medicare program.  Preventative care coverage has been expanded to cover many screenings.  Participants can take advantage of an annual wellness exam to plan which screenings are appropriate for them each year.  Healthcare reform included changing the “donut hole” provision to Medicare’s drug coverage (part D) and the donut hole will be phased out by 2020 (the donut hole is a period in which recipients pay all drug costs when they reach a certain cost level, up until reaching catastrophic coverage).  In 2013, people who hit the donut hole will have additional help/discounts during that period.

Medicare 2013

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Some of the changes that the Affordable Care Act implemented are more provider-oriented, such as quality care incentives and penalties for things such as “avoidable” hospital readmissions.  A number of cost savings measures were implemented in order to pay for new additions, but additional cuts may be necessary if the measures do not work as predicted.  Many experts predict there will be a lot of changes in the Medicare Advantage market, as significant changes to that payment system roll out.

Medicare recently published the 2013 copays, deductibles and other Medicare costs and most are increasing slightly.  Here are some of the primary

2013 Medicare cost updates:

The standard Medicare B monthly premium will increase from $99.90 to $104.90 (higher income individuals will pay more).

The Medicare B (yearly) deductible will increase to $147.

The Medicare A hospital deductible (for stays up to 60 days) will be $1184 and the skilled nursing facility co-pay will be $148 per day (for days 21-100, the first 20 days are covered at 100%).

You can visit www.medicare.gov for more details or download Aging Wisely’s 2013 Medicare Fact Sheet.

Skilled Nursing and Rehabilitation Requirements: Lawsuit Settlement

The U.S. Department of Health and Human Services recently settled a class action lawsuit (Jimmo v. Sebelius) regarding Medicare’s coverage requirements for skilled nursing and rehab. services.  Medicare typically denies coverage for skilled nursing and rehabilitation (under Part A) if a patient does not demonstrate an ability to improve.  This class action lawsuit addressed patients who need skilled nursing and rehabilitation services to manage a condition (which may not be expected to improve) or maintain their current health.

Patients must still demonstrate a need for skilled care and meet all of the other criteria (visit medicare.gov or grab a summary at EasyLiving.com Paying for Home Care Tips).  Many patients rely on “custodial care” (help with activities of daily living, household assistance), which will remain outside the scope of Medicare coverage.  However, this change could have significant impacts on patients who have chronic conditions and rely on occasional skilled care and therapy to maintain functioning and health.

These changes will be rolling out over the next several months to providers and consumers.  In the meantime, a number of Medicare beneficiaries who were denied benefits for skilled services (before January 18, 2011 when the lawsuit was filed) will have their claims re-examined.  It is an important issue to be aware of and seek help if you (or a loved one) feel you are being denied services under these new standards.  You can file an appeal through Medicare’s appeals process or seek help from a patient advocate to understand requirements, care options and ways to appeal or find alternatives.

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