More Patients Expected to Fall Between the Medicare/Medicaid Cracks

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While the upcoming expansion of Medicaid and the individual insurance mandate as part of healthcare reform will mean a larger percentage of the population will have some form of coverage, it also will create headaches for providers who will be forced to untangle exactly what benefits a patient should receive.

A new study by a patient-rights organization, the Medicare Rights Center, has pinpointed several classes of beneficiaries who are at risk of falling through the bureaucratic cracks when the expansion of Medicare and the individual insurance mandate kick in on Jan. 1, 2014 as part of the Patient Protection and Affordable Care Act (ACA).

“A Bridge to Health: Ensuring Seamless Transitions from Health Insurance Exchanges and Medicaid to Medicare,” is written for lawmakers and for consumers, but the report contains a wealth of information that providers should find useful to help prepare for the potential chaos these new coverages will create among certain patient classes.

The transition will prove particularly thorny to three classes of patients, the report states:

  • Beneficiaries enrolled in qualified health plans who become Medicare-eligible. The transition from their current plan, from which they will be required to unenroll, to enrolling in Medicare, if not appropriately timed, will create a gap in coverage.
  • Beneficiaries who fall under Medicaid’s umbrella when it expands, who then become eligible for Medicare. This patient class “will need to navigate the enrollment processes for both Medicare and Medicare subsidy programs,” the report states.
  • A smaller population of beneficiaries that will become Medicare-eligible, but will still qualify for full Medicaid benefits “under the existing, more restrictive Medicaid eligibility rules that apply when they become Medicare-eligible,” the report states. “These vulnerable individuals are at particular risk of a disruption in coverage and care if they are required to navigate the existing, more complicated pre-ACA Medicaid application, determination and enrollment processes.”

The report calls for lawmakers and government policymakers to streamline enrollment procedures. “To avoid confusion and disruptions for those new to Medicare, the federal government, states, insurers and exchanges can build on policies included in the ACA and other programs that are meant to streamline and facilitate benefit enrollment.”

Should the government fail to heed this advice, it will fall to providers to help these at-risk populations get the coverage to which they are entitled. While the government and insurers will be able to get their money from patients caught in the transition. For example, Medicare will collect late enrollment penalties for those who unenroll from their insurance but fail to enroll with Medicare in time; patients who fail to unenroll before switching to Medicare will suddenly find themselves paying two sets of premiums, meaning they will have less available income to pay their provider.

To get paid, providers will also have to assist patients in finding and enrolling in Medicare Savings Programs or in the Low-Income Subsidy program. As today,it frequently falls to providers to help patients sort out their respective coverages.

The hope is that the federal and state governments are heeding the ACA and creating mechanisms to streamline enrollment. With less than a year to go, providers should not count on it, so a concerted effort should be made to come up with contingencies. As Bette Davis put it in “All About Eve,” “Fasten your seat belts, it’s going to be a bumpy night.”

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Posted in Denials Management, Medical Receivables, Patient Access, Patient Experience, Patient Financial Services .

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