Archive for the ‘Medicare’ Category

I could retire if I had a dollar (better make it five dollars) for every client who had been told she would not qualify for further Medicare nursing home coverage because she was no longer improving or had “plateaued”.

Nonsense. Time to bust a myth!

Medicare Nursing Home Basics

Medicare pays a limited amount of nursing home care, but the care that is paid can be critical to the patient. In order to qualify, however, the patient must meet specific requirements.

First, the patient must have been hospitalized for at least three days. Second, the patient must be admitted to the nursing home for at least one of the underlying conditions treated in the hospital.

Third, the nursing home resident must receive skilled level of care on a daily basis. “Skilled services” actually cover a broad array of services. A common reason given for cutting off Medicare coverage is that “skilled services” are longer needed when, in fact, the patient indeed requires skilled services as broadly defined under the Medicare regulations.

What is “Skilled”?

Skilled services require technical or professional personnel such as registered nurses, licensed practical nurses, physical, occupational or speech therapists. In order for a service to qualify as “skilled”, it must be so inherently complex that it can only be safely and effectively performed by, or under the supervision of, professional or technical personnel.

Importantly, skilled services can include “observation and assessment of a changing condition” as well as “overall management and evaluation of a care plan”. So, for example, monitoring of fluid and nutrient intake might be necessary to prevent dehydration.

The Level Truth About Plateaus

Often nursing homes may mistakenly require a resident to be improving or showing progress in order to continue skilled services and maintain her Medicare coverage. If a resident “plateaus”, or the nursing facility says the resident no longer has rehabilitation potential, the facility may deny her further coverage. Denying Medicare coverage for this reason is improper.

The Medicare regulations are clear that “restoration potential” is not a valid reason for Medicare coverage denial. Other regulations provide coverage for “maintenance programs based on initial evaluations and periodic assessments”. A number of court cases prohibit the use of “rules of thumb” and require individual assessment of an individual’s needs.

Unfortunately, the “improvement standard” has wriggled its way into the system and is improperly applied at all levels, from nursing homes to the appeals level. One reason may be that there are so few advocates who are aware of the rules and who have the skills to appeal a coverage denial.

Improper denials often harm those most in need of help. These include not only older patients, but also those with disabilities such as Multiple Sclerosis, Alzheimer’s, Lou Gehrig’s, spinal cord injuries, diabetes, and others.

Fortunately, the Center for Medicare Advocacy recently announced an effort to combat this myth. The first approach is to prod the federal regulators to issue clear guidance. If that does not work, litigation will follow.

Wish them luck!

Ask anyone with a Social Security disability determination for a quick description of the process and be prepared for something like: Agony. Or glacial. Or maddening.

There may be a glimmer of hope for some. On February 12 the Social Security Administration added to the list of conditions that will be considered under the compassionate allowance program, which is a fast track approach to making disability determinations. Among those conditions is early (young age) onset Alzheimer’s disease. More on that below.

Why This Might Be Important

Social Security disability determinations are important for a number of reasons. As most know, all those years of payroll taxes fund a mandatory federal retirement benefit called Social Security. Work enough, turn 62 or so, stop working and collect retirement benefits. But what of the younger worker who becomes disabled?

Social Security Disability Income benefits are essentially an advance payment of retirement benefits for the younger disabled (former) worker. The extra income is nice, but the added bonus is that two years after Social Security says the disability began the (former) worker also collects Medicare. (Why a two year wait? It’s a mystery.)

Medicare is the mandatory federal health insurance program that normally goes along with the Social Security retirement benefits. That can be a godsend for the disabled individual who is no doubt racking up medical bills and may have no other health insurance (remember, she hasn’t been working a few years).

A Social Security disability determination is also important for the younger disabled person who is truly destitute (she can’t work, she’s disabled, and she doesn’t have any significant work history). Supplemental Security Income is a small benefit with all sorts of strings attached. But it has one very important feature: The doors to Medicaid instantly swing open. Medicaid is the federal health insurance program for the poor disabled.

Getting One Is Another Matter!

Getting the determination is another matter and not for the faint hearted. Years of budget cuts and under staffing have taken a toll. Overworked and under trained caseworkers make erroneous decisions and often do not understand what they are doing.

Good administrative law judges (the ones who straighten out the decisions made by the overworked and under trained caseworkers) are overwhelmed. Getting on a judge’s docket can take months . . . up to a year.

A final decision can take years. The process is so complex that lawyers can actually make a living at it . . . why else are all those ads on TV?

Cutting Through The Mess . . . For Some

That is why the compassionate allowance program can make such a difference to someone with a listed condition. Social Security Administration has determined that the conditions shown are easy to prove with a simple records review. Experience has also shown that people suffering from the listed conditions always win . . . eventually . . . a determination.

So, the thinking goes, why not fast track those conditions. Early onset Alzheimers disease is now one of those conditions. A break for those with a heartbreaking condition.

For a full list of the listed conditions go to www.ssa.gov/compassionateallowances. There are 88 conditions listed. Someone lucky (or unlucky) enough to be on the list may be on the way to a speedy determination.

Coastal Senior is a monthly periodical published in Savannah, Georgia and circulated throughout the Georgia and South Carolina low country. Bob Mason is its legal columnist.

In case you missed my last column, I am not a fan of Medicare Advantage Plans. Proponents of the plans will tell you they offer “more options” to seniors. In my experience “more options” often is code for “more complex”.

Advantage Plans also cost the taxpayers more. The government pays about 20% more to insurance companies for each Medicare beneficiary than it pays directly to doctors and hospitals on behalf of Medicare beneficiaries under traditional Medicare.

I came down particularly hard on Medicare Advantage “Private Fee for Service Plans” – a type of plan that promises much, often comes up short, and has been accused by the government of using overly aggressive (not to mention illegal) sales techniques (like forgery).

All of this is my opinion. I imagine there could be reasonable people who would disagree – and there actually may be some happy Medicare Advantage enrollees who have experienced some – umm – advantages to Medicare Advantage.

Some Important Considerations

In case you really want to take a look at a Medicare Advantage Plan, consider the following:

• Are your favorite doctors and hospitals covered by the plan? Do they accept the plan’s terms and conditions?

• Do you need a referral to see a specialist?

• Can you get care outside the plan’s service area or network? How?

• What costs are involved in the plan (premiums, deductibles, copayments)?

• Are there copayment requirements for lab tests, diagnostic tests, x-rays, MRI scans, or CT scans?

In case you want that “nice young man” from the insurance company to come by, consider:

• It’s OK to have someone with you when you discuss a Medicare Advantage Plan or any insurance product with an agent. If an insurance agent comes to your home uninvited, make an appointment to meet the agent at a time and place that is convenient to you. Do not invite strangers into your home.

• Obtain the agent’s business card so you can contact him or her later.

• If you are satisfied with your current coverage, you do not need to change.

Bailing Out

Speaking of changing, you need to get a handle on how (and how often) you can change from one type of plan to another – say from traditional Medicare to an Advantage Plan and back. Oh, alas! More complexity.

If you enroll directly in an Advantage plan for the first time upon becoming Medicare eligible or you have dropped a Medigap (Medicare Supplement) ONCE, you can voluntarily disenroll from their plan anytime within the first 12 months of enrollment. If it has been more than 12 months since enrollment, there are limitations as to when you may disenroll. Read on.

First you have an Annual Election Period (AEP), which runs from November 15 through December 31. If you are in a Medicare Advantage Plan you can switch to Original Medicare (and a Part D Prescription Drug Plan) or you can switch to a different Medicare Advantage Plan. Changes will take effect January 1 of the following year.

Next you have an Open Enrollment Period (OEP) for Medicare Advantage that runs from January 1 through March 31 of each year. If you are in a Medicare Advantage plan with Prescription Drug coverage you may switch to another similar plan offered by another company or return to Original Medicare and select a stand-alone Part D Prescription Drug Plan. You may not switch to an Advantage Plan that does not provide Medicare Prescription Drug coverage.

There are a host of other complexities on the types of plans you may switch from or to. Remember: all of this is meant to provide you with options! Just imagine the vista of possibilities opening before you!

My best advice is to be aware that November 15 begins a time when you can make some changes. Do your homework and explore those changes.

Unfortunately, I do not have space for specifics. But once you locate a new plan, you’ll need to notify both your old plan and Medicare. KEEP COPIES OF EVERYTHING.

Get help from a knowledgeable friend, adult child, or counselor.

Occasionally government does work well. The US Marines are one example. Another good example is federal funding of state programs to help seniors with Medicare and other health insurance issues. They work well and have trained counselors.

In Georgia you may find help through the Coastal Georgia Area Agency on Aging. Call them at 1-800-580-6860 and scream “HELP!”. You can also call the GeorgiaCares State Health Insurance Information Program at 1-800-669-8387.

In South Carolina call the low country office of Insurance Counseling Assistance and Referrals for Elders Program (I-CARE) (whew!)at 843-726-5536 and scream “HEY-YELP!” (They sound different in South Carolina – my opinion). By the way, the South Carolina I-CARE website is excellent: www.state.sc.us/ltgov/aging/Seniors/ICARE.htm.

We need a KISS Program (Keep It Simple Silly), but I’m NHMB (Not Holding My Breath).

Next month, one of my favorite topics: Living Trusts . . . you might just be able to live without them.

Bob Mason, certified elder law attorney by the National Elder Law Foundation, practices in Savannah, Georgia, and Asheboro, North Carolina. Email Bob at ram@masonlawpc.com or visit www.masonlawpc.com.