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Medicare reimbursement refers to the payments that hospitals and physicians receive in return for services rendered to Medicare beneficiaries. The reimbursement rates for these services are set by Medicare, and are typically less than the amount billed or the amount that a private insurance company would pay.
Four ways to adjust your Medicare coverage
If you're like most Medicare enrollees, you probably aren't planning to make any changes to your existing coverage for the coming year, but – like most beneficiaries – you should probably at least consider it during Medicare's open enrollment period. And if you have Medicare Advantage, you also have an opportunity to change your coverage between January and March each year.
Important Medicare enrollment dates
Enrollment dates for Medicare are critical. Missing an enrollment date could cost you higher premiums down the line — or it could cost you coverage entirely.
Falls are all too common with seniors: as many as one in four people over 65 fall each year and 3 million or more of them will require a trip to the emergency room. Falls can increase your risk for complications like head injuries and fractures – and falling once increases the chance you will fall again.
To prevent falls from happening (or recurring), it’s important to review your risk factors and to take steps that could improve your safety. That may require an evaluation by your healthcare provider.
Every Medicare enrollee gets a health risk assessment as part of the Welcome to Medicare Visit and the Annual Wellness Visit. The Welcome to Medicare Visit is a one-time visit offered to Medicare beneficiaries during their first 12 months of Part B coverage. The Annual Wellness Visit, on the other hand, is offered once every year but no sooner than 12 months after the Welcome to Medicare Visit. All of these visits are provided to Medicare enrollees free of charge.
The health risk assessment includes a range of screenings, one of which is a fall risk assessment. A fall risk assessment will identify medical conditions that might contribute to walking or balance problems.
The assessment also takes into consideration vision changes, and the need for proper fitting shoes – and identifies potential safety considerations in an enrollee’s home (such as throw rugs on the floors, broken or loose stairs, or the need for installation of grab bars in the shower). The health risk assessment will also assess an enrollee’s ability to perform activities of daily living (ADLs) at home.
If you have had a serious fall or have had recurrent falls, you may require a more thorough evaluation than the assessments offered through the Welcome to Medicare Visit and Annual Wellness Visit. Depending on your situation, you could require a separate office visit that requires a physical examination and additional testing with laboratory tests and/or imaging studies. These evaluations will be covered by Part B but you will be required to pay the Part B deductible (if you haven’t already met it earlier in the year) and 20% Part B coinsurance for your visit and any medically necessary tests.
A fall risk assessment may detect safety issues in your home but that does not always mean that Medicare will provide coverage to address them. For example, Original Medicare does not cover the cost of grab bars for your shower, shower seats, traction strips, or walk-in tubs for the bathroom. It also does not cover the cost of stair lifts or modifications that could improve wheelchair access, i.e., wheelchair ramps or widening of doors/hallways.
Some Medicare Advantage (MA) plans, however, may include coverage for some of these items and renovations. In 2020, the Centers for Medicare & Medicare Services allowed MA plans to expand their supplemental benefits to include safety devices and home modifications for people who were chronically ill or who showed a medical need.
The catch is that not all plans are offering these particular benefits at this time. In 2023, only 10% of individual Medicare Advantage plans and 14% of Special Needs Plans (a specific type of Medicare Advantage plan) cover bathroom safety devices. And in 2022, only 0.6% and 1.2% of these plans, respectively, covered Special Supplemental Benefits for the Chronically Ill (SSBCI) that included home modifications.
If these are services you need, you will need to look closely at what supplemental benefits a particular plan covers and what requirements must be met in order for you to take advantage of them.
To arrange for a fall risk assessment, reach out to your healthcare provider to schedule your Welcome to Medicare or Annual Wellness Visit. It will be done as part of the health risk assessment that is included with these visits.
If you have already had one of these visits this year and you need a more urgent evaluation – because you have had a recent fall or recurrent falls – you can schedule a routine office visit with your healthcare provider. When scheduling your appointment, explain that you have had recent fall(s) and let them know that you need a fall risk assessment.
Tanya Feke M.D. is a licensed, board-certified family physician. As a practicing primary care physician and an urgent care physician for nearly ten years, she saw first-hand how Medicare impacted her patients. In recent years, her career path has shifted to consultant work with a focus on utilization review and medical necessity compliance. She currently works as a physician advisor at R1 RCM, Inc., where she performs case reviews for hospitals nationwide.
Dr. Feke is an authority in the field, having Medicare experience on the frontlines with both patients and hospital systems. To educate the public about ongoing issues with the program, she authored Medicare Essentials: A Physician Insider Reveals the Fine Print. She has been frequently referenced as a Medicare expert in the media and is a contributor to multiple online publications. As founder of Diagnosis Life, LLC, she also posts regular content about health and wellness to her site at diagnosislife.com.