MEDICARE Part A OR MEDICARE Part B?
Medicare Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. For using this part of your insurance to get therapy in your home, it usually requires a qualifying hospital stay or certain surgeries that require you to be homebound while still needing complex care. This level of care includes nurse visits, as well as intermittent Physical Therapy, Occupational Therapy, and/or Speech Therapy and must be used within 14 days of your hospital or skilled nursing event. This is best for when the person continues to need more nursing services and less therapy due to medical complications. Medicare Part A restricts how often a person can receive therapy services. This is important to know when deciding what level of care you feel you need most. Medicare Part B is best used when you no longer need the skills of a nurse to visit and really need more intensive therapy care to progress your skills within the areas of physical, occupational and/or speech therapy. There are no restrictions under Medicare Part B on how often you can be seen as long as it is medically necessary and requires the skills of a licensed therapist.
HOW DO I SWITCH FROM MEDICARE Part A TO MEDICARE Part B?
If you are receiving home health services under Medicare Part A (often referred to as a “Home Health Episode”) and no longer need the skilled services of a nurse, but are ready for more intensive or ongoing therapy you should request a discharge from your home health agency from your Medicare Part A benefits. Many home health agencies are not providers for Medicare Part B benefits, so you would either have to go to an outpatient center/private practice or find a mobile therapy company that comes to you.
NEVER PAY MORE THAN YOUR 20% CO-PAY UNDER ORIGINAL MEDICARE Part B
Under your original Medicare Part B benefits you will have a 20% co-pay (unless you have supplemental insurance). But how do you know if you are paying your therapist too much? One way is to visit The Fair Health Consumer and look up the codes provided on your superbill. This is much easier than trying to understand the Medicare Fee Schedule. Most agencies will have rates that are much higher than what Medicare allows. However if the provider is enrolled with Medicare, when providing therapy services to anyone with original Medicare benefits they must lower their rates to the Medicare Fee Schedule or lower. If the provider is not enrolled with Medicare, they may charge up to 115% of the allowable rate for their services. If you have a Medicare Replacement Plan (also called Medicare Advantage), this is considered Medicare Part C benefits. You would have to stay within your network to receive the low cost rates your plan has negotiated for you. However, with more and more people acquiring these replacement plans due to their low cost another big issue is arising: long wait times and/or no available specialist in your area. In this case, you can call your provider and request authorization to see a therapist that is outside of your network. We have many patients that come to us with this issue and have great success getting coverage. Confusing? Absolutely. If you have questions about whether your insurance will cover your therapy services with Cobalt Therapy, please call or email us with your questions and we will do our best to help!