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Affordable Care Act heavily favoring Medicare over Medicare Advantage Plans

By September 22, 2014December 20th, 2022No Comments

With open enrollment for Medicare creeping closer many of those eligible may want to look at the fine print of the Affordable Care Act (ACA) before opting for coverage as this law appears to be designed to benefit those that choose to stay within Original Medicare instead of selecting a Medicare Advantage Plan (MA Plans).

Apparently, the ACA has created a very unique program to bring home health care to the chronically ill that will benefit only those enrolled in Original Medicare while leaving participants of MA Plans out in the cold to fend for themselves when it comes to Home Health Care.

On page 286 of the Affordable Care Act there is a section titled “INDEPENDENCE AT HOME MEDICAL PRACTICE DEMONSTRATION PROGRAM”.

This program, as quoted from page 286, is designed to “test a payment incentive and service delivery model that utilizes physician and nurse practitioner directed home-based primary care teams designed to reduce expenditures and improve health outcomes in the provision of items and services under this title to applicable beneficiaries.”

A more clear interpretation can be found through the Centers of Medicare & Medicaid Services (CMS) where they have defined this program as being designed to “test the effectiveness of delivering comprehensive primary care services at home for beneficiaries with multiple chronic conditions”.

The goal of this initiative is to see if implementing this type of care nationwide can not only improve conditions for those Medicare beneficiaries who have numerous chronic conditions but, also decrease the overall costs Medicare faces each year.

And the reason why this is such a boon for Medicare and a giant raspberry for Medicare Advantage Plans is the definition of who can participate in this program.

On page 288 of the ACA the eligibility requirements for those those that can participate in this program as those who:

  • Are entitled to benefits under part A and enrolled for benefits under part B;
  • Are not enrolled in a Medicare Advantage plan under part C or a PACE program under section 1894;
  • Have 2 or more chronic illnesses, such as congestive heart failure, diabetes, dementias chronic obstructive pulmonary disease, ischemic heart disease, stroke, Alzheimer’s Disease and neurodegenerative diseases, and other diseases and conditions designated by the Secretary which result in high costs under this title;
  • Have within the past 12 months had a nonelective hospital admission;
  • Have within the past 12 months received acute or subacute rehabilitation services;
  • Have had 2 or more functional dependencies requiring the assistance of another person (such as bathing, dressing, toileting, walking, or feeding);
  • Meet such other criteria as the Secretary determines appropriate.

Yes, if you have a Medicare Advantage plan, at the time of needing this type of care, you will not be eligible to become part of this program, but please keep in mind that this one program should not be the focal point of any decision making.

It is strongly recommended that you meet with a professional who understands both Original Medicare and Medicare Advantage Plans before making any decisions on what may be best for you in terms of your health coverage in retirement.

For more information on what the costs may be for Home Health Care please visit for free access to Jester Financial Technologies’ Scepter Software.

Dan McGrath