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Is Romtech covered by Medicare?

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1. Overview

Romtech is a rapid minimum-access persistent technology for making non-visual and very discreet examinations or interventions inside the body. This is generally a form of technology to help diagnose or treat medical conditions, particularly through the use of microtechnology and robotics. An example might be to diagnose vestibular problems using a self-contained robot that can steer around the semicircular canals, or an intervention to treat cerebral aneurysm by placing ‘virtual’ clips to divert blood flow. These are real examples of work that is already being pursued. RAT is a departure from conventional methods (e.g. laparoscopy) and so efficacy for the new method must be proven. Medicare is coverage with evidence development (CED). It is a method of coverage determination that provides national non-coverage for a specific item or service. This is provided only in the context of formal studies in which beneficiaries participate in clinical research to evaluate the effect on health outcomes. Then only if the assessment of the technology in specific studies proves the item or service improves health outcomes for Medicare beneficiaries, can there be a national coverage decision (NCD) to provide the item or service. (van et al.2024)(Hancock et al., 2024)(Empey et al.2021)(Markovitz et al., 2021)(Sun et al., 2022)(Gerke et al., 2020)

1.1. Introduction to Romtech

The rise of technology in medicine has been an ongoing topic for a number of years. A particularly intriguing case is that of Romtech and its ROM II System. This system is designed to aid in the recovery of acute stroke victims. The main claim for this technology is that it could help patients recover significant motor function within a short period of time, something that is truly groundbreaking. This device works by using a robot and a dedicated computer system to aid a healthcare professional in moving a patient’s paralyzed limbs in natural patterns. ROM II safely assists the patient’s arm or leg in a task-oriented repetitive manner, while measuring and recording objective kinematic and kinetic patient performance data. ROM II has been designed for persons in the sub-acute and chronic stage of hemiparetic stroke, and for the clinician to know that the patient is actively working to improve their motor skills.

1.2. Understanding Medicare

The last part is Medicare Part D. Part D adds prescription drug coverage to original Medicare, some Medicare Cost Plans, and Medicare Private Fee-for-Service Plans. These plans are offered by insurance companies and other private companies approved by Medicare.

Medicare Part C (Medicare Advantage Plans) is a type of Medicare plan offered by a private company that contracts with Medicare to provide you with all Part A and Part B benefits. Medicare Advantage Plans also include coverage for other services that Medicare does not cover.

Step two is Medicare Part B. It is medical insurance used for services or supplies that are needed to diagnose or treat your medical condition and also services to prevent and includes outpatient care. Outpatient care is defined as a patient that visits a hospital, clinic, or associated facilities, but does not spend the night. Part B also covers doctor’s visits and other medical expenses.

Step one is Medicare Part A. It is hospital insurance for inpatient hospital stays. Part A also provides care in a skilled nursing facility, hospice care, and home health care if you do not have long-term care or custodial care. Most people do not have to pay for Medicare Part A because they paid Medicare taxes while working for at least 10 years.

Medicare is a health insurance program for people age 65 or older, people under age 65 with certain disabilities, and those that work and have certain diseases. It is a program administered by the US Department of Health and Human Services. Medicare is broken down into 4 parts labeled A-D.

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2. Coverage of Romtech by Medicare

Despite the fact that the condition for coverage of patient care technology is considered to be narrow, from past Medicare policy, the National Coverage Determination Manual 310.1, it is difficult to determine. This defining monoline and verdict, while straightforward for was decided upon for the very reason written into the decision memo, to be transitional and transitory with a predictable endpoint. This in and of itself does not bar the coverage of innovative technology, though the minimum requirements for national coverage are not met. Stimulating the decision to neither open nor close a formal coverage determination with no tracking record and a constantly moving target may suggest that determination of the coverage would better be a case example to the healthcare provider. Eligibility will rarely be awarded in the long run as even if coverage were to be determined today, it would be obsolete when the technology becomes non-transitional with a clear endpoint. Though this sheds a glimmer of hope towards the consideration of coverage for new and innovative technology, to further evaluate eligibility, specific national or local coverage determination necessitates a simple decision yes or no concrete end date, a start date if the decision differs from the usual policy, and a tracking record. National coverage has never been the case for any form of technology in the healthcare industry; Romat cTech included and LCDs often overlap NCDs with the only difference being that an LCD applies coverage at a regional level. Awareness of this has often led technology developers to assume that their product is not up to par with coverage eligibility.

2.1. Eligibility criteria for Medicare coverage

Medicare Part B is essentially the same as Part A in terms of who it covers including its availability and its services. There are two main differences between A and B. The first is that Part A is free for most individuals whereas Part B requires a monthly premium. The second is that Part A is definitely a prepaid service since whether an individual knows it or not, the tax revenue funding Medicare is deducted from every paycheck. Part B is an optional service since its costs are partially paid by the recipient as well as general revenue funding from the government. Unfortunately for Romtech, the second difference will be the sole reason why Part B is not an option. Given the services of Romtech, some of the employees may be eligible for Part B if they decide to retire. At this point, Romtech may want to consider ceasing its employee health care benefits if the objective is to have retirees switch over to Medicare. (McPhee et al.2022)(Eason et al.2024)(Berlinberg et al.2024)(Cypress & ORLANDO, 2021)

Medicare Part A is available to individuals 65 and older, as well as individuals with disabilities under 65 and people of all ages with End-Stage Renal Disease (ESRD). The majority of persons with ESRD are not eligible for Medicare unless they are 65 and older. ESRD is defined as permanent kidney failure requiring a transplant or dialysis. As Medicare was designed for individuals 65 and older, Romtech will not be eligible under this part. However, if Romtech were to take on some older employees, Medicare Part A may be an option if they are uninsured and are looking for affordable health insurance.

In order to define the eligibility of Medicare coverage for Romtech, it is important to understand the basic framework of Medicare and its priorities. Medicare was established to provide health care for individuals 65 and older. It is designed to offer predictable, affordable, and high-quality health care as well as prescription drug coverage. Medicare is the largest health insurance in the U.S., and the coverage consists of many parts including Part A: Hospital Insurance, Part B: Medical Insurance, Part C: Medicare Advantage, and Part D: Prescription Drug Coverage. In order for Romtech to be eligible for Medicare coverage, it must be within the range of what type of health care Medicare was designed for and what it covers.

2.2. Types of Medicare coverage

Part C and D are not traditional forms of Medicare coverage and are only available to Medicare beneficiaries who qualify for Part A and B. Part C, also known as the Medicare + Choice plan, is an alternative to traditional Medicare coverage. It is a program offered by private health insurance plans to provide all Part A and B benefits and often includes Part D coverage. This type of program would be more suitable for RomTech employees who have Medicare Part A and B. Part C allows individuals to receive a health plan from managed care organizations or private plans. This would be advantageous to RomTech as it could be seen how to negotiate a deal with these health care organizations to provide suitable employment injury care for employees covered under Part C. (Naci et al.2022)(Anderson et al.2022)(Feldman et al.2021)(Decarolis et al.2020)(Tseng et al.2020)(Sen et al., 2020)(Romman et al.2020)(DeJong et al.2020)(Nekui et al.2021)

Part B is a paid subscription form of coverage. DaPrano outlines in her article that it is important for employers to provide health insurance that will act as the primary form of coverage in order to avoid Medicare paying out as the primary payer for work-related injuries (p. 367). This is significant as this would dissuade employees from claiming work-related injuries under Medicare Part A. Medicare Part B covers outpatient expenses for Medicare-eligible individuals and also provides medical insurance benefits for those who are covered under Part A. This would be a secondary form of insurance coverage for employees at RomTech and would be beneficial for those employees who are not covered under Part A. Both Part A and B are not actually insurance plans but rather methods of receiving a patient’s service.

When creating a health insurance model for RomTech, it is essential to understand the various forms of Medicare coverage. As outlined by Basu and Altice, Medicare coverage comes in 4 basic forms: Part A, Part B, Part C, and Part D (p. 244). Part A is the most common form of Medicare coverage and is mostly paid for. It covers hospital, skilled nursing facility, and some home health care services. This form of coverage is essential for RomTech as it needs to ensure that it is able to provide health care for employees who suffer from work-related injuries. This form of coverage is also important as Medicare Part A also covers care for patients who receive inpatient services for treatment of an injury or illness.

2.3. Potential coverage options for Romtech

In context of the entire Medicare program, there is widespread dissatisfaction amongst physicians regarding recent and upcoming changes to Medicare reimbursement. With upcoming payment reductions and freezes to funding of physician services, there may be growing interest in finding alternative funding sources for services provided to Medicare beneficiaries.

Another study found that the vast majority of neurologists believe that telemedicine encounters, compared to face-to-face encounters, are covered differently by insurers and Medicare. Of those who had experience billing telemedicine encounters to Medicare, 38% reported that the encounter was covered while 62% reported that it was denied. Those who were successful in obtaining Medicare coverage cited positive results for both teleconsultations and store-and-forward encounters. Although these numbers are disappointing, the belief that different coverage exists implies that findings could differ with clarification of Medicare policy, and successes indicate that there is potential for telemedicine coverage with refining of the Medicare benefit category for specific services. (Majmundar et al.2022)(Kyle et al.2021)(Datta et al.2021)(Wahezi et al.2021)(Chwa et al.2022)(Davis et al.2020)(Hill et al.2024)

Do thoughts physicians and Romtech administration have regarding the viability of Medicare coverage for Romtech services? According to the JMCG survey, the majority of respondents believe that a variety of Romtech services would be classified as “medical” or “skilled” (81.4% and 77.0%, respectively). This is similar to O’Brien’s findings where respondents felt that telemedicine services are currently reimbursed as “medical” (83%).

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3. Benefits of Medicare coverage for Romtech

The benefits offered by Medicare include easy access to affordable healthcare services and a greater ability to budget for these services. RomTech officers and temporary employees are eligible for hospital insurance (Part A) after working at least 6 months with a company contributing to Medicare, even if they are not yet receiving retirement benefits. Our employees can remain eligible for this coverage even if they are no longer working (for example, they are still covered during someone’s extended period of hospitalization or illness with no premium required). In addition, Medicare medical insurance (Part B) is voluntary and participants pay a monthly premium. Because Part B coverage is optional, participants can drop it if they feel that it is not worth the cost. If one is not eligible for free Part A coverage, he can purchase Part A and Part B coverage from the SSA. Low-income persons are eligible for coverage under Medicaid. With a growing number of retirees, RomTech workers will find it beneficial to have a safety net insurance program such as Medicare.

3.1. Access to affordable healthcare services

Historically, Romani people have difficulty accessing health care services for a multitude of reasons, including social, economic, and cultural barriers. The most evident barrier to access care is cost. Medicare will be of great benefit to the Romtech community as the most fundamental benefit is the access to services in which most Romani people are currently missing out on. Under Medicare, Romtech people will be entitled to services at little or no cost to themselves. This greatly assists those who are of low income and for whom health service costs are a burden. With key worker families and elderly people who live on the aged pension, no-cost services such as doctor’s visits, specialist services, and in-hospital treatment will greatly increase the likelihood of seeking care as well as improve health outcomes. With little or no cost to a service, preventative health care can be utilized. This will greatly reduce the overall cost to society of addressing chronic health problems that are prevalent within the Romani community. By increasing access to health services to both prevent and treat illness and disease, Medicare will greatly increase the health status of Romtech people and reduce the health inequalities between the Romani and non-Romani Australians. (Eason et al.2024)

3.2. Prescription drug coverage

The second option must provide the same level of coverage as the drugs you would receive in Part A or B Medicare, which means you are likely to receive the same or similar coverage you have for your Romtech treatment.

There are two options for Medicare drug coverage: 1. Medicare Prescription Drug Plan (Part D). These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans. 2. Medicare Advantage Plan (Part C). If you are in a Medicare Advantage Plan (like an HMO or PPO), the plan in essence takes the place of Part A, Part B, and usually Part D.

Prescription drugs (such as those that will be dispensed during medical treatment) play a role in the rising cost of health care. Medicare prescription drug coverage is insurance that lowers your out-of-pocket costs for drugs that are prescribed and obtained at a pharmacy.

3.3. Preventive care and wellness programs

The preventive care and wellness benefits available to all Medicare beneficiaries are widely considered to make a significant contribution to the health and quality of life of the population of older adults. The evidence base for the benefits of specific preventive services for the elderly remains less than for younger populations, particularly in terms of long-term health outcomes. However, the logic of preventing deterioration of health and functional status in order to maintain independence and quality of life and averting the onset of illness or injury that leads to costly treatment and loss of function is highly compelling. Medicare coverage of preventive services is designed to help achieve these goals. This is important for Romtech given it has a relatively high proportion of employees aged 65 and over who are eligible for Medicare. In view of the extensive existing evidence on the links between physical activity and health and the large and increasing proportion of older adults who are physically inactive, the provision of regular physical activity programs to all Medicare beneficiaries could have substantial benefits for the health of populations covered by different parts of the Medicare program. In addition to promoting a healthy lifestyle, it is important that appropriate preventive services are available to address the specific health needs of individuals. Requirements for coordinated care and case management for those with chronic conditions and the incorporation of health risk assessments into annual wellness visits offer potential for considerable innovation in how best to improve the health and well-being of older adults at risk of functional decline and those with complex health problems. These initiatives are particularly relevant to employees and dependents of employees in peacetime healthcare system roles which are being implemented in the Royal Australian Air Force who are covered by Medicare via the Departments of Veterans’ Affairs arrangements. (McPhee et al.2022)(Eason et al.2024)(Salem et al.2021)(Cypress & ORLANDO, 2021)

3.4. Flexibility in choosing healthcare providers

Although the majority of Medicare services are covered at any facility across the US, sometimes you need to confirm whether you will be covered before receiving treatment. In particular, it is important to understand the limitations of physician and non-physician practitioner services described in Medicare’s publication. Here you can acquire specific information on the types of services that can be provided by different healthcare workers. This may affect the way you utilize your Medicare benefits, as you may require certain treatments from a specialist.

Being based in an emergency healthcare service, Romtech believes this will be a significant benefit to employees as they will be able to easily locate the nearest doctor for a specific treatment and not have to wait for a doctor to be referred. This benefit is also an advantage over Medicare Advantage plans, where benefits such as urgent and emergency care are the same as or sometimes even included in some plans, better care at a lower cost.

Members of original Medicare have the flexibility to choose their own doctors and hospitals. Typically, you should see physicians who are enrolled in Medicare, but there are some exceptions for clinically necessary services. For instance, you can have treatment from a non-enrolled physician if you have an emergency or the doctor is in the US and you need kidney dialysis treatment in another country.

This is because Medicare Part A and Part B are treated as a package. They are your original Medicare benefits and provide more limited coverage, so Romtech expects to enhance this package with Medigap and Medicare Part D.

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4. Limitations and considerations

Potential out-of-pocket costs for Romtech – As a follow-on from the previous section, it is important for patients to realize that they may still be required to pay some costs even if they are receiving a Medicare benefit. The above legislation means that if a patient is looking for a product or service that has a Medicare benefit but is deemed not ‘reasonable and necessary’ for the patient, then RomTech will have to bulk bill the patient for these services. This situation is ideal for the patient as they will have to pay no additional costs but is not feasible for Romtech, who will not be able to claim the Medicare rebate and charge an additional cost for the patient. (Cypress & ORLANDO, 2021)

Exclusions and limitations of Medicare coverage – Medicare coverage is restricted to products and services that are ‘reasonable and necessary’ for the treatment of an illness or injury (cite)(sec1862). This restriction means that any services or products provided by Romtech must be medically necessary for the patient to have Medicare coverage. If the product or service is not considered ‘reasonable and necessary’, then there is no possibility of Medicare coverage regardless of any other circumstances. Furthermore, if a patient is looking into gaining an item that is costed greater than the Medicare benefit, then they will be required to pay the difference in costs.

4.1. Exclusions and limitations of Medicare coverage

Part B (medical insurance) covers medically necessary and preventive services. It also covers the cost of outpatient services and those that do not require an overnight stay in the hospital. Physician’s services are also included in this coverage. This includes services by specialists and general practitioners. Medicare will pay for 100% of the schedule fee when patients are treated in the hospital as outpatients. This is important as Romtech has many patients come to outpatient clinics and also has many patients treated at the general practitioner level. Physician’s services may or may not be covered by Medicare if the government decides that the service is not clinically necessary. If this is the case, the patient will have to pay the full fee with no Medicare rebate. This type of service will not be covered by Medicare. Services provided by doctors that are deemed clinically necessary to the patient’s health are most likely to fall under Medicare coverage and are also important to Romtech. Preventative services are covered by Medicare in an attempt to stop or slow the progression of an illness or disability. This can be from screening services, immunizations, and health education services. All of these services are expected to fall under Medicare coverage. Part B also covers allied health services that are considered necessary to patients with a chronic condition. This is a major area of focus for Romtech and its patients. A chronic condition is at least 6 months or longer, and the patient must have or be likely to gain a Medicare-approved team care plan. Services covered include those provided by a psychologist, optometrist, chiropractor, and physiotherapist. These services are expected to fall under Medicare coverage if they are considered necessary to the patient and if the patient has a team care plan. Acute allied health services are only covered by Medicare if the service is proven to be medically necessary and would be time-limited in nature, e.g., rehabilitation. This service is not expected to fall under Medicare coverage. (Barnett et al.2021)(Aggarwal et al., 2022)(Agarwal et al., 2022)(Hoagland & Shafer, 2021)(Willink et al.2020)(Taylor et al., 2024)

Medicare covers a wide range of treatments and services, but it does not cover everything. Part A (hospital insurance) will help pay for care in hospitals as an inpatient, home health care, and hospice care services. This coverage is, however, based on whether the care is medically necessary, i.e., it is necessary to treat the patient’s condition. If the patient is an inpatient for care that is not medically necessary, then the service will not be covered. If the patient goes into a private hospital, extra costs may be incurred as only public hospital costs are covered. Pharmaceutical services for admitted patients are also covered at the cost of the medications. This is important as Romtech has around 40% of its patients admitted to the hospital. These services and treatments are considered essential to the patient’s health and will most likely fall under Medicare coverage. It is mainly the more elective services that will not be covered by Medicare.

4.2. Potential out-of-pocket costs for Romtech

Medicare recipients are not classified as inpatients or outpatients, but instead as kidney dialysis patients. This is important because Medicare does not cover the same services for kidney dialysis patients as it does for inpatients and outpatients. Those who are receiving dialysis treatments only qualify for Medicare Part B. This means that the 80% of approved charges covered by Medicare applies to Romtech on dialysis, rather than the 80% coverage provided under Medicare Part A. Since Romtech is under 65 years old, he is still considered to be in the waiting period for social security, and therefore does not currently qualify for Medicare. This is crucial because once an individual becomes eligible for Medicare, it is incredibly difficult for them to be approved for social security income due to the social security disability regulation which was implemented in 1972. Medicare is allowed to deny coverage of services for individuals who are unwilling to apply for treatments which could potentially improve their health condition. This also places individuals taking part in home-based dialysis treatments in a difficult situation because although it allows them to remain in a comfortable environment and practice more flexible treatment scheduling, there is no specific Medicare home dialysis program and the same eligibility and coverage procedures apply. This may lead individuals to a decision to switch to an in-centre based treatment in order to receive better cost coverage, therefore potentially causing changes in their initial decisions concerning initial dialysis modality. Typically, patients are entitled to Medicare coverage during the first two years of social security disability benefits. However, it is possible for coverage to be extended if an individual is deemed to be eligible in the month of their 30th month of social security disability benefits. This extension of Medicare coverage also applies to individuals who have been diagnosed with ESRD and are already receiving Medicare.

4.3. Alternatives to Medicare coverage for Romtech

The criteria for veterans to be eligible for the DVA healthcare system is quite complex. In general terms, it is available to Australian veterans, peacekeepers, certain mariners, members of the Australian Defence Force, Reservists, and their dependents. It is based on the individual’s eligibility and the circumstances in which they were involved, which has resulted in a disability or medical condition, whether it has an identified causal relationship to ADF service, peacekeeping service, or hazardous duty as a mariner. DVA may provide treatment for any medical condition by an eligible person. Treatment may include medical and surgical treatment from general practitioners or specialists, hospital treatment, or pharmaceuticals. This type of treatment is provided through DVA Gold or White cards. The DVA healthcare system is intended to provide greater support and flexibility in the care of veterans and war widows or widowers. The system is open-ended and treatment may be provided for conditions that are not covered under specific guidelines and also ‘specific condition treatment,’ which is in relation to research findings on the treatment of a condition. This may be particularly relevant for any war-related injuries in veterans over age. Eligibility to DVA treatment by dependents is a result of it being available to the entitled veteran. DVA provides an extensive range of health and related care services, and Romtech may find it relevant to compare the ease of access and the coverage of medical services that are relevant to him. This system is not set to change and will continue to be relevant for veterans over the next 20 years.

The Australian government provides a number of alternatives to Medicare coverage for Romtech, which aim to provide the same or similar coverage as Medicare in specific areas. Some of these alternatives are quite complex and involve Romtech fulfilling specific criteria or passing through a number of stages before becoming eligible. In these circumstances, Romtech may become eligible for the alternative before it is implemented nationally. The alternatives are available in specific areas and the information provided here is only a guide to determine whether the alternative may be suitable for Romtech.

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