Posts Tagged ‘medicare’

Eldercare Locator – A Free, Public Service For Connecting Older Adults and Caregivers with Community Resources

October 27, 2010

The Eldercare Locator is a service of the U.S. Administration on Aging.  It’s been around for nearly 20 years.  Its toll free number is 800-677-1116.  Its website is http://www.eldercare.gov.  It  provides information about long-term care alternatives, transportation options, caregiver issues and government benefit eligibility.  This information is also available in Spanish and other languages.  There is an extensive database of links, publications, and other resources.

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Medicare Coverage of Skilled Nursing Care – The Right Standard

October 18, 2010

I have heard, all to frequently, about people losing Medicare coverage for skilled nursing care because it had been determined that they had reached a “healing plateau.”    That is, they were not improving from the skilled nursing care they were receiving (and would not improve from additional skilled care) and, therefore, were deemed to be only receiving “custodial care”, not the skilled nursing services required for Medicare benefits.

While that may have been the standard in the past, it is not the standard today, but it still comes up.  As it did recently, when a federal judge ruled against the Social Security Administration and rejected  “Improvement” as a criterion for continuing Medicare skilled nursing facility (SNF) coverage.  Here is a summary of the case.

A federal district ruled that an administrative law judge (ALJ) with the U. S. Centers for Medicare & Medicaid Services (CMS) improperly denied Medicare benefits to a patient in a skilled nursing facility. The ALJ had concluded that “[i]t became apparent that no matter how much more therapy the Beneficiary received, she was not going to achieve a higher level of function.”

After undergoing hip replacement surgery on April 28, 2008, Mary Beth Papciak, 81, developed a urinary tract infection and was readmitted to the hospital. On June 3, 2008, Ms. Papciak was discharged by Dr. Tuchinda to ManorCare to receive skilled nursing care, physical therapy and occupational therapy. Upon Ms. Papciak’s admission to ManorCare, Ms. Papciak was unable to ambulate and could not use her walker due to numbness of her hands due to what was later diagnosed as carpal tunnel syndrome. Ms. Papciak also had a history of cellulitis, anemia, cholecystectomy, chronic atrial fibrillation, hypertension, anxiety and depression.

Ms. Papciak received therapy five days a week; however, she made slow progress during her stay. Her therapy included physical and occupational therapy, treatment, self care, therapeutic exercises and therapeutic activities. Her initial treatment was primarily for ambulation. Medicare paid for the skilled care Ms. Papciak received from June 3 through July 9, 2008. It was determined, however, that effective July 10, 2008, Ms. Papciak no longer needed skilled care because Ms. Papciak had made only minimal progress in some areas, had regressed in other areas, and had been determined to have met her maximum potential for her physical and occupational therapy. As a result, Medicare denied payment from July 10 through July 19 because Ms. Papciak was only receiving “custodial care,” not the skilled nursing services required for Medicare coverage.

Ms. Papciak appealed the decision denying coverage, and her appeal worked its way up the chain to an administrative law judge, which upheld the denial, which was then upheld by CMS’s Medicare Appeal Counsel (MAC). After exhausting her administrative remedies, Ms. Papciak sought relief in federal district court.

The federal district court sided with Ms. Papciak. The proper legal standard to be applied to a patient entitled to Medicare benefits in a skilled nursing facility is whether the patient needs skilled services to enable her to maintain her level of functioning.

In the CMS Medicare Skilled Nursing Facility Manual which sets forth the standard to be applied, the reviewing authorities must give consideration to a patient’s need for skilled nursing care in order to maintain her level of functioning. The relevant portion reads: “The services must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time, or the services must be necessary for the establishment of a safe and effective maintenance program.”

Neither the ALJ nor the MAC addressed Ms. Papciak’s need for skilled nursing care in order to maintain her level of functioning. This was error, held federal Magistrate Judge Cathy Bissoon, requiring that the decision to deny her benefits be overturned.

The ALJ had concluded that “[i]t became apparent that no matter how much more therapy the Beneficiary received, she was not going to achieve a higher level of function.” Similarly, the MAC stated that “[d]espite the appellant’s arguments to the contrary, the enrollee made little or no progress in therapy from the time of her admission to ManorCare through her discharge from skilled care on or around July 10, 2008.”

This is a common misunderstanding about Medicare’s skilled nursing facility benefit, that the patient must be showing “progress” in order for Medicare to pay for her care. Indeed, federal regulations state that “[t]he restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”

What happened to Ms. Papciak? She was hospitalized again, discharged to a different skilled nursing facility, where she received physical and occupational therapy under the Medicare benefit, and was discharged home on August 21, 2008.

Medicare Part D Changing

October 13, 2010

In the coming year, seniors will see some of the biggest changes to Medicare Part D since the prescription benefit became available in 2006. More than 17 million are enrolled in private drug plans offered through Medicare.

The program’s benefits will improve for those who land in the program’s prescription drug coverage gap, the so-called donut hole. It has been announced that the nation’s pharmaceutical manufacturers will provide 50 percent discounts on the cost of the covered brand-name prescription drugs for beneficiaries in the Medicare Part D coverage gap starting in 2011.

Benefits of the Affordable Care Act for seniors include the provisions in the law that help fight fraud and make certain preventive care and annual wellness exams remain free for most Medicare beneficiaries.

The average 2011 Medicare prescription drug plan premium will remain similar to rates beneficiaries are currently paying – an increase of $1. Most Medicare prescription drug plan premiums will remain stable next year and beneficiaries will find there are clearer plan options, including many plans that can help them save even more. They will find that the Affordable Care Act improves the value of drug coverage they get next year.

Finding at-home help for aging parents

July 20, 2010

When an older relative starts to need help to get through the day, many families want to avoid institutions. To keep their loved one at home, they need to either hire a home-care aide or become one.

There are two main kinds of in-home care. Personal or home-care aides provide companionship and support a person’s activities of daily living such as dressing, bathing, preparing meals and doing laundry. Home health aides may do all those things plus tasks such as administering medication or recording changes in a client’s condition. They also may work under a nurse’s supervision.

Here are questions to ask when thinking of hiring or becoming a caregiver.

What kind of care do you need and can you afford?
Before looking for a home-care worker, families need to make sure they can afford to hire one. Families typically pay for these services out of pocket unless the older person meets Medicare’s coverage conditions or has a private long-term care insurance policy that covers such needs.

If you don’t know what kind of care is needed, a specially trained geriatric care manager can help. Assessments cost about $500 to $800 depending where you live. The Alzheimer’s Association offers assistance with an always-open phone line at (800) 272-3900 and at www.Alz.org/carefinder. Medicare’s website has a Home Health Compare tool.

Rates from $14 to $22 an hour for non-medical in-home care are typical, but keep in mind that assisted-living facilities can run $2,800 to $4,400 a month. Agencies’ rates often are toward the top of the scale. Caregivers who work independently tend to be less expensive.

Should you hire an independent worker directly or go to an agency?
The advantage of using an agency is that it takes responsibility for paying wages, taxes and insurance. Agencies also run criminal background and driving-record checks, and provide back-up aides should the main caregiver get sick or go on vacation.

Families who decide to hire someone on their own should make sure they follow all state and federal employment laws, including any provisions for overtime pay. You don’t want someone going after your estate or the family member’s estate because something wasn’t handled correctly.

How do you find the right home-care aide for your needs?
Experts recommend interviewing at least six candidates. Families should interview applicants in the home so the aides know in what kind of environment they would be working. For example, having a smoker or pets in the home may be an issue. And don’t forget to include the elder’s input. Finally, don’t balk if someone who stands out is a little more expensive. Paying a little more for someone you really like is worth the extra cost.

Do you have a plan to take care of yourself?
If you’re caring for a loved one yourself, you need to plan time away to tend to your own physical, social and emotional needs. If you don’t, you risk health-draining burnout. Churches, synagogues and volunteer groups may offer short-term relief. Adult day-care centers may be another option. The Alzheimer’s Association and Agency on Aging groups also provide respite-care resources. For overnight breaks, check with assisted-living facilities, which may offer furnished rooms, meals and nursing staff on a temporary basis.

Family caregivers can find more resources at www.familycaregiving101.org, a website run by two non-profit organizations.

More Changes to Medicare

June 30, 2010

As of June 1, people shopping for Medicare supplement insurance, or Medigap coverage, have some new options. Insurers have started selling two new lower-cost Medigap policies and stopped offering four others. At the same time the federal government, which regulates Medigap benefits, started requiring plans to cover at least a portion of hospice costs. Changes in Medicare

Medicare doesn’t pay for everything. Because patients are required to pay a portion of some of their bills, about 89% of the 47 million people with Medicare have some form of supplemental health insurance. Many opt for a federally subsidized private Medicare Advantage plan or they receive supplemental coverage from a former employer. Close to one-fifth purchase a Medigap policy.

These plans are sold by private insurers and offer standardized menus of benefits. As with most insurance policies, the more benefits you want, the higher the premium.

Whether the recent changes to these plans have an impact on you depends, in part, on when you purchased your Medigap policy. If you enrolled before June 1, you can hold onto your policy – even if it’s no longer being sold – and your benefits won’t change. Consumers are not required to purchase a new plan.

The changes apply only to Medigap plans sold after June 1. On that date, insurers stopped selling some of the plans partly because those plans offered some benefits now covered under original Medicare or Part D prescription-drug plans.

The new options charge lower premiums than most Medigap plans, but consumers must pay a higher share of the cost for various services, such as paying half of the $1,100 deductible for hospitalizations, or paying $20 for each doctor’s visit and $50 for emergency services.

Regardless of which Medigap policy you choose, if you are buying now, you will receive a new benefit covering some portion of the cost of drugs and respite care that are part of hospice care. The hospice benefit isn’t available to people who keep their existing plans, so some consumers may be tempted to switch plans. But there are potential downsides to doing so.

In many states, insurers are required to issue Medigap policies only under certain circumstances, such as when someone age 65 or older applies for coverage within six months of enrolling in Medicare Part B, which covers doctors’ visits. So someone who tries to switch plans at a later point may be denied coverage or charged a higher premium due to existing health problems or advancing age.

For more information on Medigap plans, visit medicare.gov and the Medicare Rights Center’s site (medicareinteractive.org). You can also contact your State Health Insurance Assistance Program or your state Department of Insurance.

Enroll for Medicare Online

April 20, 2010

The Social Security Administration (SSA) has just launched a new service that allows people to enroll online for their Medicare benefits even if they are not yet ready to file for Social Security benefits. About a half million Americans enroll in Medicare each year without applying for Social Security benefits.

The new online Medicare application makes it easier for people to enroll in Medicare. It saves a trip to the Social Security office, and you can complete the application at your own pace at home. The SSA says it takes less than 10 minutes to complete.

You can use the online Medicare application if you are at least 64 years and 8 months old, do not want to start receiving Social Security benefits in the next four months, and live in the U.S. or one of its territories or commonwealths. The application guides you through a brief set of questions that will help you consider either filing for Social Security and Medicare benefits, or filing only for Medicare. There are links to more information for people who have questions.

To use the new online application, click here.

Continued Travails of a Baby Boomer

January 13, 2010

Like many, I get my health insurance through my spouse’s employer. It’s great coverage, but things really change when I turn 65 and am eligible for Medicare. I will no longer get coverage. That is not necessarily the result for all employer plans. You need to check the actual policy to be sure.

In any event, I have to make sure I have alternative insurance in place when I turn 65. I don’t want to be like a client I once had who also lost coverage at 65 and assumed that he was automatically enrolled in Medicare. He continued to work and did not apply for Social Security. About three months after turning 65, he had a major medical problem that cost tens of thousands of dollars. That’s when he found out that he did not have insurance and did not have Medicare. He was on the hook for all of it. Needless to say, it put a dent in his retirement plans.

Medicare has four components: Part A is hospital insurance, Part B is medical insurance (physicians, outpatient services, medical supplies and home health care), Part C is the alternative option of managed care, and Part D is the prescription drug benefit.

People are automatically enrolled in Part A when they apply for Social Security. For people like me who are not going to apply for Social Security until later, there is a separate Medicare application. I intend to get started on that application at least 90 days before I turn 65.

I am also going to get Part B. It’s not hard because everyone who gets Part A is automatically enrolled in Part B. You have to decline enrollment if you don’t want it. I am going to enroll in Part B (regardless of whether or not there is coverage under my wife’s insurance at that time) because there is a 10 percent penalty tacked on to the premiums for each 12 months of delay after age 65. I don’t want that additional cost later.

Besides Medicare, I am going to get long-term care insurance and a medigap policy. A medigap policy is health insurance sold by private insurance companies to fill the gaps in Medicare plan coverage. Medicare does not have any really effective benefits for long-term care, whether in the home, assisted living, or a nursing home. Medicare has gaps in coverage (some great names for them… donut holes). These policies will address those gaps.

We are all waiting anxiously for the outcome of the continuing healthcare debate in this country. It’s likely to go on for quite some time. But these are my conclusions for handling the baby boom problem, especially if you are not retiring at 65.

“It takes as much energy to wish as it does to plan.” – Eleanor Roosevelt