Medicare Advantage Plans to Offer Greater Benefits in 2019
|Medicare Advantage Plans to Offer Greater Benefits in 2019|
On April 2, the Centers for Medicare & Medicaid Services (CMS) expanded how it defines the “primarily health-related” benefits that insurers are allowed to include in their Medicare Advantage policies. As a result, when these plans roll out their coverage for 2019, new benefits may include air conditioners for people with asthma, healthy groceries, rides to medical appointments, home-delivered meals, and non-skilled home-care services.
In this issue of The ElderCounselor, we will look at how Medicare Advantage Plans work, the benefits they provide, what the expansion means, and how it may impact both seniors and the plan providers.
Medicare is government-sponsored health care for those age 65 years and older. Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Part B covers doctors’ services, outpatient care, medical supplies, and preventative services.
However, there are deductibles and copayments for Medicare that can add up quickly. Also, there is no limit on annual out-of-pocket expenses. Most people buy a supplemental insurance policy, called Medigap insurance. It “fills in the gaps” of Medicare and pays deductibles and copayments. These policies are sold through private insurance companies approved by Medicare. Prescription drug coverage is also sold separately as Part D through private insurance companies.
Many seniors like the flexibility this combination provides because they can go to any health care provider or facility that accepts Medicare. Medicare pays its share of the approved amount for covered health care costs first, and then Medigap pays its share. However, Medicare can and does deny coverage for a procedure or treatment that it rules is medically unnecessary, and Medigap will only pay its share if Medicare pays first.
Also, there are some expenses that Medicare does not cover that are important to seniors, including hearing aids, vision care and dental care.
What Are Medicare Advantage Plans and How Do They Work?
Medicare Advantage Plans, sometimes called Part C, are sold by private insurance companies as an alternative to Original Medicare. If you join a Medicare Advantage Plan, you still have Medicare, but you receive Part A (hospital insurance) and Part B (medical insurance) coverage from the Medicare Advantage Plan, not from Original Medicare. However, Original Medicare will still cover the costs for hospice care, some new Medicare benefits, and some costs for clinical research studies.
Medicare pays a fixed amount for care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare and they must cover all of the services that Original Medicare covers. However, if one chooses a Medicare Advantage Plan, they cannot use a Medigap policy. In fact, it is against the law for someone to sell a senior on a Medicare Advantage Plan a Medigap policy unless that person is switching back to Original Medicare. (Changing plans is allowed once each year, during open enrollment in the fall.)
Medicare Advantage Plans work like HMOs and PPOs. Generally, a Medicare recipient must use facilities, physicians, and pharmacies that participate in the plan’s network. Some allow for non-network coverage. Emergency and urgently needed care are covered both in- and out-of-network.
One of the draws for seniors is that Medicare Advantage Plans offer benefits that Medicare does not, including vision, hearing, dental, gym memberships, and health/wellness programs. There are also cost savings. The monthly premium usually includes Medicare prescription drug coverage (Part D). And, while there may be a copayment for covered services, there is an annual limit on out-of-pocket costs. So, once a senior reaches a certain limit, they will pay nothing for covered services for the rest of the year.
Some Shortcomings of Medicare Advantage Plans
There is a multitude of Medicare Advantage Plans, even within one service area. This can be confusing to consumers who must re-evaluate them each year. Each plan can charge different out-of-pocket costs. They can also have different rules for how services are received, such as whether a referral is needed to see a specialist. And they usually have different networks of facilities and providers.
Each year, plans set the amounts they charge for premiums, copays, deductibles, and services. The plan (rather than Medicare) decides how much someone pays for the covered services, and it is allowed to change how much the insured would pay only once a year, on January (This is the effective date of coverage for each fall’s open enrollment.) However, they can change their network providers and facilities at any time during the year.
When considering a Medicare Advantage Plan, consumers must be diligent about understanding which facilities and physicians are included in its network, where they are located, and how to use the plan for routine and emergency care.
A plan can also choose not to cover the costs of services that are not medically necessary under Medicare, so it is advisable for a patient to check before they have the service or procedure done. If someone needs a service that the plan says is not medically necessary, they may have to pay all the costs of the service. But that patient would have a right to appeal the decision. They can also ask for a written advance coverage decision to make sure a service is medically necessary and will be covered.
Still, of the 61 million people enrolled in Medicare last year, 20 million have opted for a Medicare Advantage Plan. One reason may be that, in recent years, many families have become accustomed to HMOs and PPOs for their health insurance as lower-cost alternatives to traditional health care.
What the CMS Ruling Means
According to the CMS, the new rules will expand benefits to items and services that may not be directly considered medical treatment but will provide care and devices that prevent or treat illness or injuries, compensate for physical impairments, address the psychological effects of illness or injuries, or reduce emergency medical care. The goal is to keep people healthy and well, making it easier for them to live longer and more independently. A physician’s order or prescription will not be required, but the new benefits must be “medically appropriate” and recommended by a licensed health care provider.
Details of the Medicare Advantage Plan benefit packages for 2019 must first be approved by CMS and will be released in the fall when the annual open enrollment begins. But plan providers already have ideas of what they could include.
In addition to transportation to doctors’ offices or better food options, some health insurance experts said additional benefits could include simple modifications in beneficiaries’ homes, such as installing grab bars in the bathroom, or aides to help with daily activities, including dressing, eating, and other personal care needs. The goal is to focus on avoiding injuries or exacerbating existing health conditions.
Non-skilled in-home care services will also be allowed for the first time as a supplemental benefit, providing they compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room use.
Home health care providers have already partnered with Medicare Advantage Plans, and many believe the plans will be willing to pay for non-skilled in-home care with an eye on saving money over the long-term. Medicare Advantage Plans have greater flexibility than the fee-for-service providers have, and in many cases do not have a homebound requirement. Because they receive a set amount per patient from Medicare, they would be more inclined to provide any services, including private duty nursing, to ensure the patient doesn’t cost them more money than necessary.
What to Watch
Seniors on Medicare have said that when considering Medicare Advantage Plans, access to certain hospitals and doctors is a top priority for them. Original Medicare includes the vast majority of providers and the broadest possible provider network.
But Medicare Advantage Plans are gaining in popularity. According to CMS, in 2015, 35% of Medicare beneficiaries were participants in Medicare Advantage Plans. That number is expected to grow quickly over the next several years. New, attractive benefits coming in 2019 (especially non-skilled in-home care) will likely persuade even more seniors to join Medicare Advantage Plans.
That’s certainly good news for the Medicare Advantage Plan industry. And it will be good for seniors if it lets them stay in their homes longer and lead healthier, more independent lives.
To comply with the U.S. Treasury regulations, we must inform you that (i) any U.S. federal tax advice contained in this newsletter was not intended or written to be used, and cannot be used, by any person for the purpose of avoiding U.S. federal tax penalties that may be imposed on such person and (ii) each taxpayer should seek advice from their tax advisor based on the taxpayer’s particular circumstances.
Medicare and Medicaid: Unlocking the Mystery
Medicare and Medicaid: Unlocking the Mystery
Medicare and Medicaid have long been a mystery to many consumers. In fact, it can baffle and confuse even some of the smartest citizens. Like me, you might have thought, “I don’t need to worry about this right now.” However, it is never too early to gain a little understanding and awareness that just might help you help an aging loved one or yourself down the road. As the saying goes, “Time flies.”, and you will be there sooner than you think. Let’s break it down and learn some of the differences and basics of Medicare and Medicaid to unlock the mystery.
Medicare is a health insurance program provided through the federal government. In order to receive Medicare, a person must meet certain requirements. A person must be 65 years old or older or have a severe disability. In order for a disabled person under the age of 65 to be eligible for Medicare, they must have received Social Security Disability Insurance (SSDI) for two years. In order to be eligible a person must have Social Security retirement benefits or Social Security disability benefits. Because Medicare is run and administered by the federal government, it is uniform from state to state. If a person meets Medicare eligibility requirements, they can receive Medicare no matter their income or assets. Costs for Medicare are based on the recipient’s work history. This means that costs are determined by the amount of time a person paid Medicare taxes. These costs like all insurance include premiums, copays, and prescriptions.
Medicare can be confusing because there are four parts. The commercials talk about Parts A, B, C, D. What does it all really mean? Parts A, B, and D can be somewhat simplified. Part A is hospital insurance, Part B is medical insurance, and Part D is prescription drug coverage. Parts A and B are covered in Original Medicare offered by the government. Part C is often called the Medicare Advantage Plan. This is a private health plan. The Medicare Advantage Plan or Medicare Part C plan are required to include the same coverage as Original Medicare but usually also include Part D as well. It is important to do your homework on these plans to find what works best and is most cost effective for you.
Medicaid is a health care assistance program. Its guidelines come from the federal government, but it is administered by each state. Medicaid is for people who cannot afford to pay for their care on their own. It is based on income and assets, and is available to people who belong to one of the eligible groups. The eligible groups are children, people with disabilities, people over age 65, pregnant women, and the parents of eligible children. Seniors who require nursing home care can qualify for Medicaid and only pay a share of their income for the nursing home. Medicaid then pays the rest.
A person can be eligible for both Medicare and Medicaid and can have both. The two programs work together to help the recipient best cover the expenses of health care. For example, Medicare costs include premiums, copays, and deductibles. Full Medicaid benefits can cover the costs of Medicare deductibles and cover the 20% of costs not covered by Medicare. Medicaid can also help with Medicare assistance and may cover costs of premiums for Part A and/or Part B.
Although Medicaid and Medicare can be quite confusing, it is important at a minimum to know the basics. When you or someone you love is eligible or in need of the benefits, there are organizations willing to help and your elder law attorney is also a valuable resource.
If you have any questions about something you have read or would like additional information, please feel free to contact us.
Medicare’s Expansion of Telehealth Benefits
Medicare’s Expansion of Telehealth Benefits
Medicare is expanding telehealth benefits for its members. Telehealth is defined by the Health Resources and Services Administration of the U.S. Department of Health and Human Services as the use of electronic information and telecommunications technologies to support and promote long distance health care, patient and profession health-related education, public health and health administration. Through telehealth services, Medicare beneficiaries can save money and the time of running back and forth to the doctor. A variety of telehealth benefits will be more readily available to Medicare beneficiaries, especially for chronic medical issues, but these can be dependent on qualifications for the services as outlined by the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act.
All Medicare recipients will be eligible for telestroke evaluations. The geographic restrictions for telestroke consultations will be eliminated beginning in 2019. Emergency medical workers will be able to call in to doctors if they suspect that a patient is having a stroke. The doctor can evaluate the symptoms on the spot, allowing emergency workers to begin treating a patient on the way to the hospital. Another service available to Medicare beneficiaries remotely will be the monitoring of dialysis patients. Telehealth services for dialysis had been only available to patients deemed living in remote areas, but these restrictions will also be lifted beginning in 2019. The benefit of both of these services is evident. One allows patients to begin treatment earlier and the other lessens the time patients must spend going to the doctor’s office for treatment.
The legislation that provides for the expansion of benefits provides more telehealth services to Medicare Advantage Plan B holders with multiple chronic diseases. With telehealth services, beneficiaries can receive more services. Some of these services include changing medication doses and monitoring blood pressure. In addition, patients with chronic diseases such as heart disease, cancer, or diabetes can receive telehealth services. This limits how often they have to go to a doctor’s office, which can be of great benefit to patients who may have issues with mobility. Beneficiaries will spend less time waiting and more time receiving the quality health care services they need while also cutting costs.
Long term care providers are also benefitting from Medicare’s expanded telehealth services. In many cases long term care providers do not have physicians readily available on staff and the time it takes to get a physician, especially in rural settings can be a problem. Therefore, patients have had possible avoidable transfers and admissions to other health care facilities. This can put fragile older adults at greater risks for other illnesses. Through telehealth services, physicians and practitioners can be available 24 hours a day to assess needs of patients and determine whether transfers and admissions to other facilities is necessary. This can improve the quality of care patients receive, reduce costs for the patient and long-term care facilities, and improve patient satisfaction.
Medicare beneficiaries, long-term care providers, and Accountable Care Organizations will find more flexibility in using telehealth services. These groups may find it beneficial to explore all their telehealth options and the scope of telehealth services available. Telehealth services will slowly become more commonly accepted and more readily accessible for Medicare beneficiaries. Hawaii Senator Brian Schatz tweeted about the bill, “It will increase access and quality of care, and reduce costs using tech that is already available.” Progress is being made in this telehealth services. Schatz also stated in a press release, “Almost every other part of our health system uses technology to save costs. It’s long past time for Medicare to catch up.” Providers, as well as beneficiaries, should take full advantage of the growing trend toward these services.
If you have any questions, please feel free to contact us.
Covert | Law
Covert | Law
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