What’s the Difference Between Medicare and Medicaid in the Context of Long-Term Care?

Although their names are confusingly alike, Medicaid and Medicare are quite different programs. Both programs provide health coverage, but Medicare is an “entitlement” program, meaning that everyone who reaches age 65 and is entitled to receive Social Security benefits also receives Medicare (Medicare also covers people of any age who are permanently disabled or who have end-stage renal disease.)

Brian Raphan, P.C.

Medicaid, on the other hand, is a public assistance program that that helps pay medical costs for individuals with limited income and assets. To be eligible for Medicaid coverage, you must meet the program’s strict income and asset guidelines. Also, unlike Medicare, which is totally federal, Medicaid is a joint state-federal program. Each state operates its own Medicaid system, but this system must conform to federal guidelines in order for the state to receive federal money, which pays for about half the state’s Medicaid costs. (The state picks up the rest of the tab.)

Medicare and Medicaid Coverage of Long-Term Care

The most significant difference between Medicare and Medicaid in the realm of long-term care planning, however, is that Medicaid covers nursing home care, while Medicare, for the most part, does not. Medicare Part A covers only up to 100 days of care in a “skilled nursing” facility per spell of illness. The care in the skilled nursing facility must follow a stay of at least three days in a hospital. And for days 21 through 100, you must pay a co-payment of $152 a day (in 2014). (This is generally covered by Medigap insurance.) In addition, the definition of “skilled nursing” and the other conditions for obtaining this coverage are quite stringent, meaning that few nursing home residents receive the full 100 days of coverage. As a result, Medicare pays for less than a quarter of long-term care costs in the U.S. In the absence of any other public program covering long-term care, Medicaid has become the default nursing home insurance of the middle class. Lacking access to alternatives such as paying privately or being covered by a longterm care insurance policy, most people pay out of their own pockets for long-term care until they become eligible for Medicaid. The fact that Medicaid is a joint state-federal program complicates matters, because the Medicaid eligibility rules are somewhat different from state to state, and they keep changing. (The states also sometimes have their own names for the program, such as “Medi-Cal” in California and “MassHealth” in Massachusetts.)

Both the federal government and most state governments seem to be continually tinkering with the eligibility requirements and restrictions.

This is why consulting with your elder law attorney is so important. As for home care, Medicaid has traditionally offered very little — except in New York, which provides home care to all Medicaid recipients who need it. Recognizing that home care costs far less than nursing home care, more and more states are providing Medicaid-covered services to those who remain in their homes. It’s possible to qualify for both Medicare and Medicaid. Such recipients are called “dual eligibles.” Medicare beneficiaries who have limited income and resources can get help paying their out-of-pocket medical expenses from their state Medicaid program. For details, click here.

2015 Spousal Impoverishment and Home Equity Figures:

Brian Raphan

The Centers for Medicare and Medicaid Services has released its Spousal Impoverishment Standards for 2015.

The official spousal impoverishment allowances for 2015 are as follows (we include Medicaid’s home equity limits):

Minimum Community Spouse Resource Allowance: $23,844

Maximum Community Spouse Resource Allowance: $119,220

Maximum Monthly Maintenance Needs Allowance: $2,980.50

The minimum monthly maintenance needs allowance for the lower 48 states remains $1,966.25 ($2,457.50 for Alaska and $2,261.25 for Hawaii) until July 1, 2015.

Home Equity Limits:

Minimum:   $552,000

Maximum:  $828,000

For CMS’s complete chart of the 2015 SSI and Spousal Impoverishment Standards, click here.

For more information about protecting your assets click here.

Regards,

Brian A. Raphan, Esq.

Can You Appeal If Medicare Refuses to Cover Care You Received?

Absolutely.  Sometimes Medicare will decide that a particular treatment or service is not covered and will deny a beneficiary’s claim. Many of these decisions are highly subjective and involve determining, for example, what is “medically and reasonably necessary” or what constitutes “custodial care.” If a beneficiary disagrees with a decision, there are reconsideration and appeals procedures within the Medicare program.

medicare denialWhile the federal government makes the rules about Medicare, the day-to-day administration and operation of the Medicare program are handled by private insurance companies that have contracted with the government. In the case of Medicare Part A, these insurers are called “intermediaries,” and in the case of Medicare Part B they are referred to as “carriers.” In addition, the government contracts with committees of physicians — quality improvement organizations (QIOs) — to decide the appropriateness of care received by most Medicare beneficiaries who are inpatients in hospitals.

If an intermediary, carrier or QIO decides Medicare shouldn’t pay for care you received, you will learn this when you receive your Medicare Summary Notice (MSN). The Medicare Rights Center recommends first making sure that the coverage denial isn’t simply the result of a coding mistake.  You can ask your doctor to confirm that the correct medical code as used.  If the denial is not the result of a coding error, you can appeal the denial using Medicare’s review process. Click here for details on this process.

Once Medicare’s review process has been exhausted, the matter can be taken to court if the amount of money in dispute exceeds either $1,000 or $2,000, depending on the type of claim. Medicare beneficiaries can represent themselves during these appeal proceedings, or they can be represented by a personal representative or an attorney. The Medicare Rights Center estimates that only about 2 percent of Medicare beneficiaries appeal denials of care, but 80 percent of those who appeal Part A denials and 92 percent who appeal Part B denials win more care.

 

Even if Medicare ultimately rejects a disputed claim, a beneficiary may not necessarily have to pay for the care he or she received. If a recipient did not know or could not have been expected to know that Medicare coverage would be denied for certain services, the recipient is granted a “waiver of liability” and the health care provider is the one who suffers the economic loss. In cases where this limited waiver of liability does not apply, however, the beneficiary is liable for any costs of care that Medicare does not cover. For example, a patient is financially responsible for any services normally provided under Medicare Part B if provided by a nonparticipating provider who did not “accept assignment” of the claim.

For more information email me at info@RaphanLaw.com or visit http://RaphanLaw.com. Or stay on top of these issues by subscribing to my free email Newsletters. Sample here… 

Regards, Brian

Can You Appeal If Medicare Refuses to Cover Care You Received?

Absolutely.  Sometimes Medicare will decide that a particular treatment or service is not covered and will deny a beneficiary’s claim. Many of these decisions are highly subjective and involve determining, for example, what is “medically and reasonably necessary” or what constitutes “custodial care.” If a beneficiary disagrees with a decision, there are reconsideration and appeals procedures within the Medicare program.

While the federal government makes the rules about Medicare, the day-to-day administration and operation of the Medicare program are handled by private insurance companies that have contracted with the government. In the case of Medicare Part A, these insurers are called “intermediaries,” and in the case of Medicare Part B they are referred to as “carriers.” In addition, the government contracts with committees of physicians — quality improvement organizations (QIOs) — to decide the appropriateness of care received by most Medicare beneficiaries who are inpatients in hospitals.

If an intermediary, carrier or QIO decides Medicare shouldn’t pay for care you received, you will learn this when you receive your Medicare Summary Notice (MSN). The Medicare Rights Center recommends first making sure that the coverage denial isn’t simply the result of a coding mistake.  You can ask your doctor to confirm that the correct medical code as used.  If the denial is not the result of a coding error, you can appeal the denial using Medicare’s review process. Click here for details on this process.

Once Medicare’s review process has been exhausted, the matter can be taken to court if the amount of money in dispute exceeds either $1,000 or $2,000, depending on the type of claim. Medicare beneficiaries can represent themselves during these appeal proceedings, or they can be represented by a personal representative or an attorney. The Medicare Rights Center estimates that only about 2 percent of Medicare beneficiaries appeal denials of care, but 80 percent of those who appeal Part A denials and 92 percent who appeal Part B denials win more care. 

Even if Medicare ultimately rejects a disputed claim, a beneficiary may not necessarily have to pay for the care he or she received. If a recipient did not know or could not have been expected to know that Medicare coverage would be denied for certain services, the recipient is granted a “waiver of liability” and the health care provider is the one who suffers the economic loss. In cases where this limited waiver of liability does not apply, however, the beneficiary is liable for any costs of care that Medicare does not cover. For example, a patient is financially responsible for any services normally provided under Medicare Part B if provided by a nonparticipating provider who did not “accept assignment” of the claim.

For more about Medicare, click here.

 Regards, Brian

http://www.RaphanLaw.com

Senate Looks at Doctor-Dropping by Medicare Advantage Plans:

What to do when Medicare Advantage insurers drop large numbers of doctors from their plans?

medicare-pillOn Jan. 22, members of the Senate Special Committee on Aging met in Hartford, Conn., in search of an answer. UnitedHealthcare, the nation’s largest Medicare Advantage insurer, planned to drop its contracts with some 2,250 doctors in the state on Feb. 1, but a court has ordered the terminations delayed while the issue is being litigated.

Raymond H. Welch, a dermatologist in Rhode Island, told the committee that when Medicare Advantage plans can summarily drop providers, it leaves doctors focused on pleasing the insurer instead of advocating for their patients. “It is this perversion of the doctor-patient relationship that I fear the most,” Welch said. “It is said you cannot serve two masters. The master that physicians serve must be their patients, not UnitedHealthcare.”

But attorney Stephanie Kanwit, testifying on behalf of America’s Health Insurance Plans, the industry’s national trade association, countered that insurers need the freedom to drop doctors from their networks.

“As a direct result of the serious funding challenges facing the Medicare Advantage program,” Kanwit told the committee, “the need is greater today than ever before for innovations that deliver increased value to beneficiaries with the increasingly limited resources that are available to support the MA program.” Insurers, she said, are looking at which medical providers are most cost-effective as well as which score best on measures of quality care.

Richard D. Johnson, a retiree who lives in Bridgeport, Conn., said he was disappointed and confused when the doctor he trusted was dropped from his Medicare Advantage plan.

“I just want to see the doctor who has been taking good care of me for three years,” Johnson testified. “ I want to say that I am not just worried about myself. There are lots of other seniors who are affected by this. … When you have health problems, you want to stay with the doctors who know you personally and take excellent care of you.”

Posted on 01/27/2014 by  | Washington Watch | 

Regards,

Brian

How to Use Medicare to Pay for In-Home Care

350xIt’s not easy to get Medicare coverage for in-home care, and when you do it’s strictly limited. That said, it can be a godsend when you’re faced with a sudden medical crisis or downturn in your loved one’s condition. Medicare coverage is most common when your loved one is being discharged from the hospital or a rehabilitation facility. You’ll contract through a Medicare-certified agency for a period of skilled nursing care and therapy that’s tied to a certain period of expected recovery.

The good news is that Medicare coverage is easier to get than it used to be, and it should become easier still.
Read full article…

How will the Affordable Care Act affect Seniors…

How will the Affordable Care Act affect Seniors…

How will the ACA (Obamacare) affect senior citizens

8 expensive health insurance mistakes

How to avoid paying too much for the protection you need:

cr122k11-Pill_Bottle_MoneyOn Oct. 1, America’s health care system will undergo its biggest change since Medicare’s arrival almost 50 years ago when the major provisions of the Affordable Care Act start kicking in. And although millions of people who have been without health insurance should finally be able to get it—under the law, everyone must have some kind of health coverage as of Jan. 1, 2014, or pay a small fine—the system will remain just as complex and unforgiving as it is today. That puts you at risk of being left without adequate coverage when you need it most. To avoid unnecessary fees, penalties, and just plain bad deals, here’s a list from CONSUMER REPORTS of health-insurance don’ts.

1. Assuming because you’re healthy you don’t need health insurance

If you get sick and then decide to buy health insurance from plans made available as part of the Affordable Care Act, you might not be able to, at least not right away. You’ll only be allowed to purchase individual health insurance during the initial open enrollment period—Oct. 1, 2013, through March 31, 2014. In subsequent years, open enrollment will run from Oct. 15 through Dec. 7 for coverage that begins Jan. 1. The best place to buy is your state’s Health Insurance Marketplace, a new kind of virtual insurance agency where you can compare plans and possibly qualify for income-based subsidies. The marketplaces open for business Oct. 1. So if you decide to thumb your nose at the 2013-14 deadline and on April 1 are hit by a bus, you’ll have to wait nine full months to get health insurance. And needless to say, it won’t retroactively pay for care you received when you didn’t have it. Don’t count on free emergency care, either. Although an emergency room will take care of you if you require urgent attention, even if you don’t have insurance, it will send you a bill afterward—most likely a very large one, and might make aggressive efforts to collect payment. In certain circumstances, you’ll be allowed to purchase individual insurance outside the open enrollment period. Losing insurance because of a change in employment, or moving away from your health plan’s service area, are examples of such “qualifying events.” But suddenly needing expensive health care because you are sick is not.

2. Picking a plan based solely on low premiums

 There is no free lunch in health insurance, but there is a menu of payment options to choose from. You can pay for your care up front, in the form of a higher premium, or later, in the form of a higher co-payment, a bigger deductible, or both. Neither form of payment is inherently better; it depends on your personal situation and preferences.

For instance, if you’re in generally good health and have an adequate financial cushion, you might save money with a lower insurance premium and higher cost-sharing. But if you have ongoing medical needs, you might do better with a higher premium and lower cost-sharing. Of course, you take a risk if you pick a plan with a very high deductible and co-pay and then can’t afford your share of expenses if you do happen to get sick.

One little-known benefit of the health care law is that plans sold to individuals can’t impose more than $6,350 in annual cost-sharing in 2014, no matter how low the premiums. Today it’s not uncommon for plans on the individual market to have deductibles of $10,000 or more.

(You’re legally entitled to receive a Summary of Benefits and Coverage [PDF] outlining your choices. If you don’t have one, ask your company’s insurer or benefits manager for a copy.)

3. Carelessly going out of network

 One of the big selling points of a preferred provider organization (PPO) over a health maintenance organization (HMO) is that if you have a PPO, you can opt to get your care from doctors or hospitals that don’t participate in the plan’s network, whereas with HMOs you can’t.

But the fine print can cost you if you’re not careful. For instance, if your PPO says it will pay 60 percent of the cost of out-of-network care (compared with, say, 80 percent for in-network care), it will pay 60 percent of whatever it determines is a “reasonable” price for the service—not 60 percent of whatever the doctor decides to charge. So if his fee is $2,000 and your insurance company decides that the fair price is $1,000, it will reimburse you only $600, leaving you on the hook for the other $1,400.

The way around that is to avoid going out of network except when you absolutely can’t find an in-network provider. The only time that won’t work is when you receive non-network care involuntarily, such as during a trip to an emergency room of an in-network hospital where the doctor taking care of you isn’t in the network, or when you have surgery and the anesthesiologist doesn’t participate in your plan.

Strictly speaking, you have no legal recourse but to pay those bills. Yet in practice, polite but persistent complaints to the provider or your insurer can often succeed in reducing the price.

4. Missing the Medicare sign-up deadline

 If you’re already retired or plan to retire at 65, Medicare enrollment is a no-brainer: Sign up during the month you turn 65 or the three months before or after.

Where people get in trouble is when they, or a spouse, continue working past their 65th birthday. As long as you or your spouse works at a job with health benefits and there are 20 or more employees, you will probably get little or no benefit from being on Medicare. That’s because Medicare pays secondarily to your employer’s group plan.

But once you (or your spouse) stops working and you lose your insurance—even if you can continue with the employer plan through COBRA or some other retiree benefit—you must switch to Medicare as your primary insurance. You need to sign up within eight months after you stop working. If you don’t and your private plan finds out, it can refuse to pay for your health care. It gets worse. If you don’t sign up for Medicare when you should, you’ll be hit with a permanent 10 percent premium surcharge for every year you should have been on Medicare but were not.

The surcharge usually doesn’t matter with Part A, which covers hospital care, because there’s usually no premium. But Part B, which covers doctors and most other outpatient care, costs $104.90 a month (more for higher-income retirees).

There’s a similar late-enrollment penalty for Part D, the Medicare drug benefit, but it’s calculated differently: There’s a 1 percent premium surcharge for every month you could have signed up but didn’t.

Worse still, if you wait too long, you won’t be able to enroll in any part of Medicare until the next general enrollment period, which takes place annually from January through March, and your coverage won’t start until July 1. The penalty clock will be ticking the whole time.

5. Picking the wrong Medicare drug plan

 Only 5 percent of Medicare beneficiaries who choose a stand-alone Part D drug plan are covered by the plan cheapest for them, according to a study in the October 2012 issue of Health Affairs. The average beneficiary paid $368 more in premiums and drug costs than he would have if he had chosen the cheapest plan for his specific assortment of prescriptions. And more than a fifth overspent by at least $500 a year.

The biggest mistake people make is picking a plan that pays for generic drugs in the coverage gap known as the doughnut hole, according to study authors Chao Zhou and Yuting Zhang from the University of Pittsburgh. People wound up paying hundreds of dollars more for that feature than they got back in benefits. Even if you went through the exercise of finding the cheapest plan last year, it’s smart to do it again during theopen enrollment period—Oct. 15 to Dec. 7 for 2013. Drug plans change their preferred drug lists and costs may change as well. So last year’s good deal may no longer be your best bet.

It also pays to review your Medicare Advantage options every year. You may be able to find a plan with a higher quality rating at a lower cost. That’s especially important nowadays, because Medicare gives plans with higher-quality ratings (that is, with four or five stars) more money to spend on their members—in the form of lower premiums or more services—than it gives lower-rated plans.

To see your full range of choices, ignore the brochures cluttering your mailbox because they won’t give you the full picture of your options. Instead, go straight to medicare.gov and click on the yellow oval that says “Find health & drug plans.” Follow the simple online instructions to compare all Medicare Advantage and Part D plans available in your area.

6. Not taking advantage of flexible-spending accounts

 A flexible-spending account lets you set aside money tax-free from your paycheck to pay for medical expenses not covered by insurance, such as deductibles and co-payments, as well as dental care, eyeglasses and contact lenses, and some alternative treatments.

Contributing to an FSA will also reduce your taxes. Say you have a taxable income of $75,000 a year and taxes claim 20 percent, or $15,000. If you put aside $2,500 in an FSA, your taxable income will be reduced to $72,500 and your taxes will be cut by $500, from $15,000 to $14,500. The higher your tax bracket, the greater the benefit.

Those advantages remain despite two changes in FSAs due to the health-reform law. You can no longer use money in your FSA to pay for over-the-counter drugs unless you get a prescription for them from your doctor. And the maximum amount you can set aside is capped at $2,500 for 2013 and will rise by the annual general inflation rate each year after that. Previously, employers set the cap, typically up to $5,000. Keep in mind that FSA funds don’t carry over year to year, so you must use the total amount you set aside or lose it.

 7. Failing to use your insurer’s preferred pharmacy or mail-order service
 Some commercial and Medicare Part D plans have negotiated deep discounts with specific mail-order and retail pharmacies. For example, people with Humana’s Walmart-Preferred Rx Plan can get prescriptions for select generic high-blood-pressure drugs for only a penny at more than 4,000 preferred pharmacies, including Neighborhood Market, Sam’s Club, Walmart, and Walmart Express. Other generics cost as little as $1 a month after a deductible.

People who have a Medicare Advantage plan with Part D coverage through United Healthcare can get some prescriptions for as little as $2 at Kroger, Target, and many other pharmacies. Aetna has partnered with CVS pharmacies to offer a special Medicare prescription drug plan: a $2 co-pay for preferred generic prescriptions and a $5 co-pay for nonpreferred generics. Other pharmacies are available in the network, although higher costs may apply. And if you take a generic drug regularly for a chronic condition such as diabetes or elevated cholesterol, you might get an even better deal through mail-order. The Humana plan described earlier has little or no co-pays (after a deductible) on generic drugs ordered by mail.

8. Not keeping young-adult children on your insurance

Under the health-reform act, you can now keep children on your insurance up to their 26th birthday, even if you don’t claim them as dependents on your tax return or they are no longer in school or living with you. Your workplace can’t charge a different premium for your adult children than it does for younger children. And eligibility isn’t based on their living circumstances—they can stay on your insurance even if they get married. They can also go on and off your insurance as many times as needed.

There are a couple of caveats, though. If you’re retired, you might not have the option of keeping your children on your insurance. The law doesn’t require retiree-only plans to cover adult children of beneficiaries. And Medicare doesn’t cover any dependents, period, including spouses. And if your workplace charges an extra premium for each added dependent (that’s allowed), and your young-adult child is living and working independently, it may be cheaper for her to purchase individual coverage on her state’s health-insurance marketplace, especially if she earns less than about $46,000 a year and therefore qualifies for a subsidized premium. It costs nothing to check, in any event.

Editor’s Note: This article appeared in the October 2013 issue of Consumer Reports Money Adviser.

 

 

 

 

If You Have Medicare, No Need to Go to Health Insurance Marketplace:

Today is the day the Affordable Health Care act starts to take on meaning. The government has set up a Health Insurance Marketplace–https://www.healthcare.gov –where people can sign up or learn more. However, the digital demands have overloaded the system so you may find delays in viewing pages or logging in for information. So while your waiting for the internet to clear up, you can read some info–specific to seniors with Medicare– in an article here:

While the Obama administration is stepping up efforts encouraging uninsured Americans to enroll in health coverage from the new online insurance marketplaces, officials are planning a campaign to convince millions of seniors to please stay away – don’t call and don’t sign up.

“We want to reassure Medicare beneficiaries that they are already covered, their benefits are not changing and the marketplace doesn’t require them to do anything,” said Michele Patrick, Medicare’s deputy director for communications.

Learn how the new health law works for you and your family

medicare-pillTo reinforce the message, she said the 2014 “Medicare & You” handbook – the 100-plus-page guide that will be sent to 52 million Medicare beneficiaries next month — contains a prominent notice: “The Health Insurance Marketplace, a key part of the Affordable Care Act, will take effect in 2014. It’s a new way for individuals, families, and employees of small businesses to get health insurance. Medicare isn’t part of the Marketplace.”

Still, it can be easy to get the wrong impression.

“You hear programs on the radio about the health care law and they never talk about seniors and what we are supposed to do,” said Barbara Bonner, 72, of Reston, Va. “Do we have to go sign up like they’re saying everyone else has to? Does the new law apply to us seniors at all and if so, how?”

Enrollment in health plans offered on the marketplaces, also called exchanges, begins Oct. 1 and runs for six months. Meanwhile, the two-month sign-up period for private health plans for millions of Medicare beneficiaries begins Oct. 15. In that time, seniors can shop for a private health plan known as Medicare Advantage, pick a drug insurance policy or buy a supplemental Medigap plan. And in nearly two dozen states, some Medicare beneficiaries who also qualify for Medicaid may be choosing private managed care plans. None of these four kinds of coverage will be offered in the health law’s marketplaces.

Since many of the same insurance companies offering coverage for seniors will also sell and advertise policies in the marketplaces, seniors may have a hard time figuring out which options are for them.

“Over the next six months seniors will be bombarded with information and a lot of it will be conflicting and confusing,” said Nick Quealy-Gainer, Medicare task force coordinator for Champaign County Health Care Consumers, an Illinois advocacy group.

Read full article>

Regards,

Brian A. Raphan, Esq.