Transcript (Fall Risk and Medicare)

Fall risk is the likelihood of an unintentional fall, often assessed in adults 65 or older. More than one in four adults aged 65 and older fall each year. Falls can cause injuries and lead to long-term health issues.

Before we get into Fall Risk coverage, it helps to look at what Medicare covers overall. Part A covers medically necessary inpatient hospital stays and skilled nursing facility care. It also covers hospice and some home health services. Part B includes doctor visits, preventive services, durable medical equipment, and outpatient care. Part D generally covers prescription drugs you get from a pharmacy.

Medicare A, B, and D can include co-insurance, co-pays, and deductibles.

In this video, we’ll walk through Fall Risk prevention, diagnosis, treatment, rehabilitation, and medications.

Prevention and Screening:

Prevention often starts with a simple conversation with your doctor. Medicare Part B covers most preventive services, including a Yearly Wellness visit. Those visits may support a Fall Risk prevention plan. The 5 P's of fall prevention are strategies for medical providers to help prevent fall risk. These include: pain, personal needs, position, placement, and preventing falls. Doctors may prescribe mobility aids for balance, walking, or safety issues. Part B covers medically necessary durable medical equipment, like canes and walkers.

Diagnosis

Fall risk is usually identified through self-awareness and a medical assessment. Your doctor may check strength, balance, and blood pressure. They may also review vision, cognitive changes, footwear, and the effects of medications. Medicare Part B covers many diagnostic tests, doctor visits, and outpatient care, subject to a deductible and 20% coinsurance. [medically necessary].

Treatment

Inpatient hospitalization may be needed after a fall injury.

Medicare coverage for inpatient stays begins after you meet the Part A deductible.

The Part A deductible applies per benefit period, not just once each year. Muscle weakness may be helped with physical therapy and exercise. Part B may also cover durable medical equipment, such as a walker or wheelchair.

Recovery and Follow-Up

Reduced mobility after a fall can increase weakness. Physical therapy may help rebuild strength and balance. Occupational therapy may help with daily activities and safer movement at home. Some falls may also lead to home health care or skilled nursing care. Part A applies to skilled nursing facilities when certain criteria are met. Skilled nursing care typically requires a three-day inpatient hospital stay first.  [Not including the day of discharge or time spent in the emergency room]

Medications

Medications can help treat pain, infection, dizziness, or other causes of falls. Some drugs may increase fall risk through drowsiness or confusion. Ask a doctor or pharmacist whether any of your medications may affect balance or alertness. Prescription drug coverage varies by plan rules, tiers, formulary, and pharmacy network. A formulary is a drug list covered by your Part D plan. A drug may require prior authorization, step therapy and quantity limits. Part B often covers drugs given in medical settings. In most cases, this involves drugs given via injection or infusion, and vaccines for prevention.

Medicare Advantage

With Medicare Advantage, additional rules come into play. All plans must include Medicare services; however, the guidelines can change. Network use, referrals, and prior authorization may affect access. Medicare Advantage plan rules can also affect costs and timing.

Some plans may offer extra fall-prevention benefits, such as fitness programs, transportation, or safety items.

Closing Summary

Fall risk is common, but it is manageable. Communicate any falls, near falls, or unsteadiness to your medical providers. Find the potential causes and reduce fall risks. Always confirm coverage with Medicare, your doctors, and your plan. Peace of mind comes from self-awareness and action.