Sunday, August 9, 2015

IBM Medicare OneExchange Medicare and custodial services coverage

For a number of years, I have been a volunteer with the Medicare Rights Center. From time to time I handle a call from the son or daughter of an elderly person with early dementia who is being release from the hospital after a fall or medical problem.  The caller always feels the patient is not ready to be release back home because of both their mental and physical condition. They want to know how to stop the hospital from releasing the patient. These calls are really difficult because there are no quick and easy answers to offer. The answer starts with a rather flat statement.  Medicare does not cover custodial care aka long term care.  If the patient is physically able to walk a few steps, has no other treatable medical problems, and the doctor does not prescribe any physical therapy then the hospital is going to release them.
This is the kind of situation that requires advanced understanding of Medicare coverage otherwise the caregiver will use the wrong words when appealing to the doctor, the hospital, and Medicare.  If they talk about the dementia, they will be told Medicare does not cover custodial care and appeals will be denied.
What does Medicare cover?  Medicare covers remedial care.  That is, Medicare covers rehabilitation. That can be provided in a Skilled Nursing Facility (SNF) or as an outpatient.  The purpose of remedial care is to stop the patient from getting physically worse.  It used to be that the patient had to improve. Those Medicare rules were changed about a year ago.  Knowing about Medicare remedial coverage can provide the right words to goad the doctor, hospital and Medicare into transferring the patient to a SNF and might give the caregiver some time to determine next steps as well as improve the patient's stamina.

The right words need to revolve around physical condition.  That means, in a case where the patient is elderly, the words need to be about how the patient's strength has waned from being in a hospital bed and how they need physical therapy to regain their strength before they return home or they will risk injury.  Those words are really important to use if the caregiver must do an emergency appeal to Medicare to stop the hospital from releasing the patient. The case to be made is the doctor and hospital are doing an inadequate job assessing the patient's strength and ability to walk. Risk of injury is also important to say.  DO NOT use ANY words about cognitive problems aka dementia. There is no rehabilitation for dementia.  Dementia falls into the category of long term care.

This is only a temporary fix to buy time.  The caregiver needs to do advanced planning regarding custodial care. Many people make arrangements for the elderly person to reside with them.  If that is not an option, then it may be time for a nursing home. The only private insurance that covers nursing home costs (which are substantial) is long term care insurance. The older a person, the more expensive the insurance premiums. Even for younger people, the premiums are substantial.  Medicaid is the only government insurance that provides custodial care but eligibility is limited to low income people with few assets. The rules for Medicaid vary from state to state.  In New York, if a person is low income (less than $1000/month)  and has few assets they might be eligible for Medicaid.  New York also has a program called Medicaid spend down which allows expenses for medical treatment to be subtracted from a person's income to determine Medicaid eligibility.  If the person qualifies for Medicaid, they are eligible to go to a Medicaid nursing home.  However, government budget reductions have caused the services in Medicaid nursing home facilities to diminished in recent years. It was never stellar.

AARP and other organizations are lobbying congress to include custodial care coverage in Medicare or provide people with the ability to buy into Medicaid because by 2020 about a third of our population will be over 65.  Given the current congressional opposition to the Affordable Care Act, it's a long shot. Petition your legislators if you believe more government remedies should come into play to help the elderly population deal with long term care costs.

There are no easy options for custodial care.  But knowing the right words to say if you encounter the described situation might provide you some short term relief while you consider your options.

Saturday, August 8, 2015

IBM Medicare One Exchange Fall Enrollment for 2016 Medicare Insurance

Although it is early to start thinking about Medicare insurance coverage for 2016, the Medicare Advantage insurance providers will soon start flooding our mailboxes with  advertisements.
The literature companies send out in August are typically generic descriptions of their plans.  The details for their 2016 offerings won't be "officially" available until  September.  However, it is also the time when notifications are mailed for discontinued plans and/or plan modifications (such as prescription drugs no longer being on a plan's formulary or premium increases) for your current plans.  It is easy to get inundated with marketing information and overlook important plan notifications. Make sure to read everything you get in August and September from your 2015 insurance plans.  People frequently overlook formulary changes, health plan changes and discontinuation notices that will affect their 2016 coverage. 
Before the barrage of information hits, take some time to look at the pros and cons of your current health and prescription drug coverage.  If you are dissatisfied with the cost of your coverage based on premiums, copay/coinsurance or formulary coverage - it's a good time to consider what kind of coverage you want in 2016.
The insurance policies you are able to buy in 2016, as a Medicare recipient, are offered by zip code and will be listed in starting October 15, 2015.  You'll have until December 7, 2015 to chose and enroll in a different plan. After December 7th, you will not be able to change your coverage again until October 2016 for January 2017.  The one exception to that is if you want to switch from a Medicare Advantage plan to use original Medicare.  You can do that from January 1 - February 15. But there are a lot of other implications to doing that so it is not an easy switch. None of this applies to people with Medicare Supplemental plans (aka medigaps).  The rules for when and if you can change a medigap policy are determined by your state.  Contact your State Health Insurance Assistance Program (aka SHIP) to find out those rules. The phone number can be found at
The Medicare Advantage and part D insurance companies always offer their policies based on zip codes.   If you have friends in other states or even in other counties in your state that rave about their policies, it may not help you decide on a plan because their policy might not be available in your zip code.  Also, don't forgot, the insurance policies offered through OneExchange are a SUBSET of the insurance polices you are able to buy in your zip code.  That's really important to remember.  For example, if the OneExchange prescription drug insurance policies do not provide coverage for the drugs you need or the cost of your drugs is high, look at the Rx insurance policies listed on or call Medicare (1-800-MEDICARE) to look for a less expensive Rx policy. You only need to buy ONE policy from OneExchange to be able to get your IBM HRA funding.  You do not need to buy all your Medicare insurance from OneExchange.
If you feel your 2015 insurance policies provide good coverage AND the insurance companies do not make significant changes to those policies for 2016 then there is NOTHING to do with either Medicare or OneExchange to continue coverage and get your IBM HRA in 2016.  
If you think it is time for a change then do some research and figure out your options. Do this yourself, don't rely on an insurance agent. That's like going to a Ford showroom and expecting a sales person to tell you about Toyota. Like OneExchange, insurance agents sell a subset of insurance policies you are able to buy. If you have original Medicare, a change you might consider is to switch to a Medicare Advantage plan.  Remember, once you go to a Medicare Advantage (MA) plan you trade a national coverage plan for a zip code based plan.  You also need to do a thorough job of looking at cost sharing for an MA plan. The insurance companies usually do not tell you about all the aspects of cost sharing unless you ask.  For example, ask them what is the copay for an out of network specialist or an ambulance. That might give you some insight of the true cost of their policy. Even better, ask for a complete schedule of cost sharing. Reputable companies will provide it.  Most importantly, make sure the doctors you want to see are included in the insurance policy network.  In October, look online at or call 1-800-MEDICARE to be sure your drugs are still covered by your plan and that you are not overpaying for your drugs. 
So, get ready - fall enrollment will be here before you know it!