The Difference Between Medicare and Medicaid
The Difference Between Medicare & Medicaid
Most people who work in healthcare may recognize the acronym LASA, which stands for “look-alike-sound-alike” and is usually seen when referencing medications. When it comes to federal programs, Medicaid and Medicare, in written form, look alike and they do sound alike but work very differently.
Both Medicare and Medicaid were started in 1965 under Lyndon B. Johnson’s administration in response to the inability of older and low-income people to purchase private insurance. Medicaid is an assistance program, funded federally and at the state level, that provides coverage for health care to low-income individuals regardless of age. It is governed federally with each state administering its own plan, which can vary from one state to the next. Medicare is a federal insurance program that provides health coverage for people aged 65 and over or to those under age 65 with a severe disability such as end-stage renal disease or Lou Gehrig’s disease, also known as ALS-amyotrophic lateral sclerosis. Dependents are not typically covered.
Medicaid eligibility is needs-based, meaning both income and assets are counted when determining eligibility. Both Medicare and Medicaid will cover a broad range of health care services, including hospital stays and physician office visits, yet Medicaid will cover nursing home care, in-home care services, long term care, and transportation to receive medical care which Medicare will not pay for. It is possible to qualify for dual coverage, which means both Medicare and Medicaid will work together to provide health care coverage and lower costs.
Regarding cost, Medicaid in most instances is free of cost though a small copay may be required depending on the plan. Medicaid can also recover against assets in a recipient’s estate after the death of the recipient. This could mean a lien is placed and executed on a recipient’s home, depending on whether a surviving spouse or blind or disabled child is residing in the home. Medicare is not free in that premiums and co-payments may be required for some parts of Medicare, and may be larger for those with a higher income, but eligibility is not income-based.
With Medicare, one has to work for about 10 years (40 qualifying quarters), at which point no premiums are required for Part A, which covers hospitalizations. Premiums may be necessary if you sign up for a Medicare Advantage plan, which is different from Original Medicare where you are permitted to purchase supplemental coverage for out of pocket costs. Because Medicare is not administered by each state, a Medicare recipient will usually have the same coverage and pay the same copays and deductibles regardless of the state of residence. Co-pays and deductibles are required for Medicare’s Part B (outpatient services) and Part D (medication) plans. Also, a financial penalty can be assessed if one does not sign up for Medicare Part B when you first become eligible, and there may be a delay in getting coverage.
Though basic differences are covered here, there is much more information to know regarding both plans, so research is encouraged before you hit the age of eligibility for Medicare to determine which Medicare plan may be right for you. Medicaid plans and coverage differ from state to state, and sometimes county to county. We would be happy to answer any questions you have about your potential eligibility for either program. Just give us a call at 1.800.660.7564 or email us at firstname.lastname@example.org.
Pause Before You Sign That Nursing-Home Contract
Pause Before You Sign that Nursing Home Contract
Suppose your mother can no longer make decisions for herself and she now needs nursing-home care. You are stressed and anxious. The nursing home puts a twenty-page, single-spaced contract in front of you. You wish you could flip straight to the last page and sign then and there, just to get it over with.
Do not do this. You could be agreeing to pay, out of your own pocket, many thousands of dollars for your mother’s care.
Try to get your mother admitted and then, before you sign the contract, bring it to us for our review and guidance. Once your mother has moved in, she can’t be evicted just because you want to negotiate the contract.
But if that is not feasible, then sit down and take a few deep breaths. Read the contract carefully. Make a list of questions and ask a facility representative to explain. Ideally, that person would sit with you as you go through the document. Don’t sign until you understand.
Here is what to watch out for.
You should not use your own money to pay
* Do not sign the contract if it requires you to obligate yourself to pay with your own money. Carefully scrutinize any language referring to you as the “responsible party” or “resident representative” or “agent.”
The suspect buzz-words are “co-signor,” “guarantor,” “personally guarantee,” “personally liable,” “private-pay guarantor,” “surety,” “individual capacity,” or any such language. Words like these obligate you, personally, to pay if your mother doesn’t have the money. Don’t sign even if there are no buzz-words, but the language looks something like this: “If the resident does not or cannot pay, I will pay the amount owed for residency charges, services, equipment, supplies, medication, and other charges.”
Please understand that it is legal for the facility to require you, if you hold financial power of attorney or are guardian, to pay nursing-home bills from your mother’s money and assets. It is legal to require you to spend her money on her care and not for any other purpose. It is not legal to condition your mother’s admission on your agreeing to pay her bills with your own money, which is what the above buzz-words mean in plain English. The nursing home can ask you to agree – and if they ask, refuse – but you cannot be forced to agree to pay with your own money.
If your mother lacks the money, the next step is to apply for Medicaid assistance, not to go digging into your pocket.
Sometimes the contract is confusing. For instance, one nursing-home agreement says that the representative “personally guarantees continuity of payment.” This alarming language is properly followed by an italicized statement that the representative is “not required to pay for Resident’s care from his/her own personal funds.” The agreement proceeds, though, to use the phrase “personally guarantee” in other contexts. Ambiguity like this is why we recommend that you first bring the agreement to us. We can ensure, on your behalf, that the facility clarifies such language and does not misapply it.
Everyone in need has the right to apply for Medicaid
* The nursing-home contract must not require your mother to waive – give up – her right to seek government assistance like Medicare or Medicaid, nor can it ask her or you to sign any statement that she is ineligible for those benefits.
* If your mother has no money to pay for care, a Medicaid application will be required. The contract may seek your permission to apply for Medicaid for you. You have the right to decline that option and, instead, seek legal counsel to help you apply. We have seen some facilities mishandle Medicaid applications, which wound up being denied when they should not have been.
In any case, though, whoever files for Medicaid, you must cooperate by immediately providing all records necessary for that application.
If your mother is eligible for Medicaid, Medicaid pays
* If your mother does get Medicaid, the nursing home must not require an additional payment over and above that designated by the Medicaid scheme in your State.
* The nursing home must not demand that your mother receive additional services not covered by Medicaid and then, if your mother declines those services, evict her. It should ask, in advance, whether those services are desired at specified additional cost.
* The nursing home must not require additional donations to a charity as a condition of admittance.
Do not agree to arbitration
* The contract may seek your consent to arbitration. If you agree, you will be giving up your right to a jury trial if a dispute arises. The rules are in flux at the moment, but, generally, you should decline such a provision.
The nursing home must protect property reasonably
* The nursing-home contract may try to fudge its responsibility to take care of your mother’s property, but the bottom line is that it is obligated to care for your mother’s property during her stay. You should, however, use good judgment to safeguard her valuable property like fine jewelry by keeping it elsewhere.
Protect yourself. Cross out, and sign the right way
* Cross out provisions in the contract that you decline, and put your initials by the strike-outs.
* Be sure to sign the contract only as your mother’s agent. Your signature should read: “[Mother’s name], by [your name], her agent.”
To be fair to nursing homes, they are entitled to be paid and they often have difficulty collecting on legitimate debts. Facilities are forbidden from suing to take a resident’s Social Security or pension income. They must comply with strict federal consumer-protection restrictions. Despite these payment hurdles, they must still protect frail and vulnerable people from all manner of harm. They also suffer public hostility, thanks to the misconduct of some bad actors. We always urge cooperation with nursing-home personnel if feasible, because their job is a difficult one.
On the other hand, you and your family have the right to be protected from the excesses of bad actors – or from the imperfections, for example, of the facility mentioned above that misuses the “personally liable” language. Thus, no matter how reputable the facility, it is good judgment to consult an attorney before you sign an admission contract. If that’s not possible, then take care and time to study the contract, get facility staff to explain it to you, and strike out the objectionable provisions as advised above.
A few moments of care, even despite the stressful circumstances you are surely in at the time, can save you a lot of difficulties later. Please feel free to reach out if you have questions or need assistance by calling us at 1.800.660.7564 or by emailing us at email@example.com.
Medicare Coverage for Long Term Care
Medicare Coverage for Long Term Care
Most people understand that by paying into Social Security throughout their careers, they can receive health care benefits through Medicare starting at age 65. Individuals under age 65 who qualify to receive Social Security Disability benefits are also covered under Medicare, as well as anyone of any age who has Lou Gehrigs disease, known as Amyotrophic Lateral Sclerosis (ALS), or has been diagnosed with permanent kidney disease (end-stage renal disease) that requires dialysis or a kidney transplant. But many people may not understand what is covered when long term care is needed.
In general, long term care is medical and non-medical care provided to a person who is unable to perform the basic actions needed on a daily basis to function independently.These basic actions are called activities of daily living and include bathing, dressing, eating, toileting, managing bowel and bladder function, and having enough physical mobility to be able to move safely to and from a bed or a chair, called transferring. For people with chronic diseases, permanent injury such as from a stroke, or are suffering from the effects of aging, long term care is provided indefinitely without the expectation that the patient will recover.
Often patients receiving long term care services reside in a nursing home to be able to have their basic needs met. For others who have become incapacitated due to an illness or injury, skilled nursing care may be needed with the goal of recovering to independent functional status.Medicare will pay for medically necessary acute care services and some long term care services that meet specific criteria. Most long term care non-medical services are not covered by Medicare, such as nursing home expense or the services provided in the home for custodial-type care.
There are four specific types of long term care services, listed below, that Medicare will pay for, though certain conditions apply for most services to be covered:
- Care in a skilled nursing facility for up to 100 days per benefit period
- Services to treat medical conditions
- Services to prevent further decline due to medical conditions
- Hospice care
For a Medicare recipient to qualify for a skilled nursing home stay, the patient must have been provided acute care in a hospital for three consecutive days (often referred to as three midnights) prior to transferring to a skilled nursing facility or must be placed in a skilled nursing facility within 30 days of that qualifying acute care stay. Being held on observation status for three consecutive days is not enough for Medicare to pay for additional care.
Once in a skilled nursing home, payment for services is based on length of stay with only a portion of the cost is covered after the first 20 days, and Medicare will not pay for the cost of the skilled nursing facility after the 100th day.These days of stay do not need to be consecutive.
When services to treat medical conditions are deemed medically necessary by a physician, Medicare will pay indefinitely on certain services as long as the physician writes an order for continued services every 60 days and these services remain medically necessary. Services covered include intermittent or part-time skilled nursing care, therapy services provided by a Medicare-certified home health agency, medical social services, and medical supplies and durable medical equipment (of which 80% of the approved amount is covered). For patients with conditions that may not improve, such as debility from a stroke, Parkinson’s disease, Alzheimer’s disease, Multiple sclerosis or ALS, Medicare will pay for services that could prevent further decline in their health status. Hospice care for those with a terminal illness who have chosen to stop all active treatment and are not expected to survive longer than six months is also covered with Medicare. This care includes medications for pain control or relief from the symptoms of the illness, as well as hospice care by a Medicare-approved hospice provider not only in the home but in a nursing home or a hospice care facility. Lastly, some short-term hospital visits may be covered.
Understanding how to pay for long term care can be overwhelming. We help seniors and their loved ones plan for the possibility of needing long term care, including how to access and pay for it. If we can be of assistance, please don’t hesitate to reach out by calling us at 1.800.660.7564 or by emailing us at firstname.lastname@example.org.
Modernizing Medicare to Leverage the Latest Technologies
Modernizing Medicare to Take Advantage of the Latest Technologies
Many seniors who are financially stable and choosing to age in place already have a “smart” home employing the sorts of technology that can prolong their independent living circumstances. Family caregivers are freer to move about their daily lives knowing they can check remotely on their loved one and that the loved one has a set of controls at their disposal to monitor their environment. Some of these seniors are also tracked directly by medical staff that can assess if any of the patient’s medical vital signs are outside of a safe range. While corporate competition for senior market dollars has made many of these devices within reasonable price points, Medicare is attempting to catch up to the market demand for the use of these products and include them as refundable medical expenses. Private enterprise and public policy are not in synch.
Medicare’s modest step forward in the proposed approval for funding and use of technology, specifically remote monitors for at home Medicare recipients to track blood pressure and other vital signs, is on a slow trajectory. There are two important limitations associated with the proposals. The first is a constraint on the devices eligible for use and the second is there is no provision for Medicare recipients who do not use home health agencies. The Centers for Medicare and Medicaid Services (CMS) will also not directly reimburse home care companies but allow for the expense to be considered when setting overall reimbursement rates. In other words, the bureaucratic acceptance and ability to merge even the most basic of medical technology tools into the mainstream is cumbersome at best.
While it has not been proven that these monitoring devices improve health outcomes (and may explain why CMS is moving so cautiously), the advocates for the technology make the case that the tools allow the elderly, frailer individuals the ability to continue living at home rather than moving to an assisted living or nursing facility. There is less financial strain on CMS outlays when older adults age in place. Currently, the CMS proposal only allows for technology that monitors and collects physiological data which typically includes blood pressure, glucose monitoring, and electrocardiogram (ECG). All of this data is digitally stored and can be transmitted by the patient and the caregiver. However, this sort of monitoring is currently happening, and what CMS has come up with is merely a payment change and exclusion of those Medicare recipients not associated with home health agencies. Not exactly a significant foray into at home medical technology. Technology can streamline and make effective the remote monitoring process however it becomes less effective when government policy continues to add layers of bureaucracy and exclusions that make the adaptation to remote monitoring technologies at home needlessly complicated.
What happens to the latest tech tools that can detect how well a senior is moving around their own home, forgotten to turn off the stove, or a senior who is unable to swallow a pill or answer a phone? For the many chronically ill seniors who are regularly monitored and have stabilized prescription medical approaches for their condition, it might be far more advantageous to approve of technologies that can prevent a house fire or data analytics that can be predictive about the increased risk of an unintended fall. Mobility trackers and smart home devices are as important as at home biometric devices for the senior who is choosing to age in place.
Given that technology will have to be the offset for the growing shortage of personal care workers and their associated expense, remote monitoring will become pervasive in the care of the elderly with chronic conditions. However if the senior does not have financial stability, and many of them do not, how will the costs for these home technologies be addressed?
What are the benefits of the changes CMS has made to the Home Health Prospective Payment System (PPS)? The belief is as put forward by Seema Verma, “The redesign of the home health payment system encourages value over volume and removes incentives to provide unnecessary care.” What this means is if a Medicare recipient uses a home health agency then the remote monitoring tools become an allowable cost on the Medicare report form. The expectation is to use home health agencies as the vehicle to foster the adoption of emerging technologies which is all in support of advancing the Administration’s MyHealthEData initiative. These benefits are doubtful to keep pace with market-driven forces for innovation in the field of at home biomedical devices because healthcare is taking up an increasing share of the US economy. The CMS Office of the Actuary projects that by the year 2026 one in every five dollars in America will be spent on healthcare.
Another benefit CMS has put into place is the release of the Blue Button 2.0 application programming interface (API). Blue Button is a digital platform that is now the standard for Medicare beneficiaries to receive claims data in a digital format so it can then be securely and privately used in applications (apps) developed by third parties. This platform standardization by CMS is encouraging software developers to leverage its digital architectural design for claims data from Blue Button 2.0.
CMS has taken some cautious steps to ensure that certain Medicare beneficiaries will be able to take advantage of and be reimbursed for the advances in the technologies for home health care. The US healthcare spending is forecast for continued growth reaching over $1 trillion by 2026. There is not a lot of time to get this right. Large government agencies move far more slowly than agile, market-driven technology companies. Thankfully technology developers and CMS are both starting to find ways to blend effectively and efficiently for the benefit of Medicare recipients, but it is a long road ahead. If you have any questions or concerns, please don’t hesitate to contact us at 1.800.660.7564 or by emailing us at email@example.com.
Will Social Security and Medicare Programs Run Out of Money?
Will Social Security and Medicare Programs Run Out of Money?
According to the American Association for Retired Persons (AARP), every single day 10,000 baby boomers are turning 65 years old. The deluge of aging Americans and the increase in longevity in the already 65 plus population are the main reasons why the Social Security and Medicare programs are expected to have financial insolvency issues in the coming decades. Unsurprisingly, the vast majority of baby boomers agree that it is critical to preserve Social Security benefits even if it requires an increase in taxes paid into the system by working Americans. Payroll taxes by far account for the majority of monies available to pay for social security benefits.
The boomer generation is keen to preserve social security benefits as many of them are not well prepared for retirement. The financial retirement picture for nearly half of the younger boomers (ages 55 – 64) is bleak with reportedly no retirement savings at all. The US government is also unprepared to sustain full benefit payments. By the Social Security Administration’s admission in 2034, the program will run out of reserves at which time benefits would have to be reduced by 25% unless the government can fix the programs long-term funding shortfall.
This same group of unprepared boomers also appears to have uncertainty as to how much of their income health care costs are projected to absorb. Health View Services states “HealthView Services’ Retirement Healthcare Cost Index, which calculates the percentage of Social Security benefits required to address total lifetime retirement healthcare expenses, reveals the impact of expected healthcare costs on retirement budgets. The index shows a healthy 66-year-old couple retiring today will need 48% of their lifetime Social Security benefits to address total lifetime healthcare expenses.” Additionally, about half of baby boomers believe Medicare will cover the cost of long-term care, but that is not the case.
How federal government institutions face the challenge of covering the costs of social insurances like Social Security benefits and Medicare costs to a burgeoning boomer population will determine whether many citizens will be able to age successfully. Beyond the more significant problem of funding these social programs, the government is looking to technology to cut costs for senior care. Virtual assisted living that can help families care for older adults and smart devices appear to be some of the technological saviors for the American baby boomer population.
Joseph Coughlin, Ph.D., director of the MIT AgeLab in Cambridge, MA, and others testify before the Senate Special Committee on Aging as debate about policy and program funding for American seniors can no longer be put off. Coughlin recommends that virtual reality (VR) become a standard device among senior living communities, assisted living and nursing homes. Not only did residents engaging with VR have fun, but there is also less depression and more engagement in active conversations with other residents as a by-product of the technology.
Other technologies on display include smartphone apps with health functions, smart glasses that can help prevent accidental falls for seniors with limited eyesight, and a pen that can help people with reduced vision identify items. Using these and other tech devices can create a better aging experience and reduce the need for hospitalization for many seniors. Technology provides a net benefit for programs like Medicare that routinely pay for hospitalization costs that include injuries due to falling, reactions from incorrect prescription dosages, and other emergent care needs that can be avoided with practical technology applications.
While no one can discount the importance of funding social programs that benefit aging Americans, applications of specific technologies for seniors can reduce overall costs associated with the baby boomer generation. As the federal government begins to tackle the issues at hand for seniors, there is a lesson to be learned. Putting off planning for or relying on some other entity to solve retirement and health care issues is a dangerous proposition. If you have any questions, please give us a call at 1.800.660.7564 or email us at firstname.lastname@example.org.
How to Avoid Medicare Scams
How to Avoid Medicare Scams
By far the largest types of insurance fraud are scams against government and private health care insurers. Scammers frequently target government insurance like Medicare by stealing newly issued medical ID cards and then stealing identities. The Coalition Against Insurance Fraud estimates that tens of billions of dollars are lost annually to these types of fraud. Additionally, medical identity theft is now a top complaint received by the Federal Trade Commission. Billing fraud is also responsible for huge losses to Medicare funds and is difficult to assess as it can be a billing error or intentional fraud.
How does this affect a senior on an individual level? Scammers typically pose as Medicare officials and ask people to pay for their new cards which in reality are free. Or they phone a potential victim with false news of a refund and ask for the person’s ID number and bank account number to deposit the refund. “Right now … everyone is being inundated with TV commercials, brochures and other official-looking documents in the mail about all the Medicare Advantage plans. It’s so confusing, and in an environment like that, fraud is rampant,” says Micki Nozaki of the California Senior Medicare Patrol. There are more than 50 million Medicare beneficiaries who can annually opt to swap Medicare Advantage and Part D prescription drug plans which provide scammers with the opportunity to prey on vast numbers of seniors.
The Centers for Medicare and Medicaid Services have a list of tips to help prevent fraud. The first and foremost is to protect your Medicare and Social Security numbers vigilantly. It suggests treating your Medicare card like you would a credit card and do not provide the number to anyone other than your doctor, or people you know should have it. Become educated about Medicare with regards to your rights and what a provider can and cannot bill to Medicare. Review your doctor bills carefully, looking for services billed for but not provided to you. Remember that nothing is free with regards to medical care; never accept offers of money or gifts of free services. Be suspicious of your provider if they tell you they know how to “bill Medicare” to pay for a procedure or a service that is not typically covered. Before leaving your pharmacy check to be sure your medication is correct, including the full amount prescribed and whether or not you received a generic or brand name medicine. If your prescription is in error report the problem to the pharmacist before leaving.
Remember Medicare will never visit, call, or email you and ask for personal information such as your Medicare number, Social Security Number, address, or bank account number. Medicare already has this information and does not need you to provide it. Even when Medicare issues new cards that no longer contain your social security number in April of 2019 you will not be required to do anything. You can assume that anyone who claims to be helping you with Medicare and asks for your personal or financial information is a scam artist so close the door, hang up the phone, or delete the email.
When it is time to compare plans be sure to meet with a trustworthy advisor. Some insurance representatives give the industry a bad name by selling you a policy or plan that does not suit your needs or your budget. Some agents go so far as to ask you to sign a release form allowing them to make decisions on your behalf. Never sign anything related to Medicare without first reading it carefully. Additionally, it is a good practice to have a family member or lawyer review the document before signing it. The non-profit National Council on Aging (NCOA) has a free, brief assessment that allows you to compare plans online. You can also contact your local State Health Insurance Assistance Program (SHIP). SHIPs is a provider of free, federally-funded Medicare counseling via a trained volunteer or staff member.
Medicare fraud wastes billions of taxpayer dollars annually. Carefully review your medical bills and have inaccuracies corrected. Guard your personal information vigilantly and be wary of people asking you to provide that information. Meet with a trusted insurance advisor or compare medical plan options using the sites listed above. If you are unsure about something call Medicare directly for clarification.
If you have questions or would like to discuss anything you’ve read, please don’t hesitate to contact us at 1.800.660.7564 or by emailing us at email@example.com.
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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