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Aging, the physical deterioration of the body, is a simple, undeniable fact. Every biological entity at some point over its life span begins to slow down in its ability to renew and mend itself. People are living longer today than at any other time in history. This is due, in large part, to better living standards and advances in medicine. However, the limits of the human body can be made to last just so long. Unless there is a sudden death, it is most likely there will be expenses incurred for health and/or long-term care.
This section deals with the financing of health care. As with most things in life, there are no hard and fast rules here in getting help unless you are independently wealthy. Very likely some of the financial assistance needed to care for your folks will be coming from a public source: Medicare. Because of the dramatically increased costs of caring for elderly, most people cannot assume all of these costs. In fact, Medicare is the largest health insurance program for the elderly in the country covering over 45 million persons.
It is important to stay abreast of current trends when it comes to Medicare due to constantly changing factors such as revenues derived from Social Security payroll tax, as well as political and legislative events. Remember what you are learning about now to help the folks will serve you well, in just a few years. Thus this becomes a family affair and while you help the folks they in turn are passing on valued experience to you.
ACTION ITEM: A critical item that should be discussed with the folks is that of preparing an ADVANCE MEDICAL DIRECTIVE (AMD). It is important that a responsible person is designated to make health care decisions for Mom/Dad in the event either or both are incapable. The good thing about this instrument is that a person can be specific about the types of treatment they wish to have, particularly life-prolonging treatments and technologies.
An AMD is a good means of respecting the folk’s wishes. Types of AMD’s are discussed at the end of this chapter.
Medicare is a Federal program started in 1966 under Title XVIII of the Social Security Act. Almost everyone over the age of 65 can be enrolled in Medicare. Enrollment in Medicare is either automatic or the person has to apply. Generally enrollment is automatic for Parts A and B and the Medicare Card is mailed out three months prior to one’s 65th birthday.
NOTE: Changes for 2012 – Open enrollment now begins and ends earlier – October 15 – December 7, 2011.
NEW for 2012: Learn about the “new” Blue Button on www.MyMedicare.gov you can use to access your Medicare claims and other personal health information.
A note on the current Medicare “dilemma”. Over the past few years’ news and media reports have increasingly been focused on the pending monetary shortfall of Medicare. This is a real and very complex problem. Health care costs have risen dramatically. Many would argue that much more money is required to keep the system functioning. Others claim the system must be completely overhauled, or as one Congressman put it,“putting more gas in an old car does not make it run better.”
Because costs have gone up so much over the past several years the government has placed controls and complex regulations on virtually every aspect of the system. The cost of every doctor visit, hospital stay, almost everything is now regulated. When Medicare was created in 1965 it was meant to assist seniors with their private health care systems. Today Medicare is the health care system.
The news we get from Washington is that ongoing funding for Medicare is a major topic of debate and concern. It is advised to keep current with ongoing developments. This is a major concern for you, your folks and everyone.
Is your folk’s health insurance any of your business?
Parents capable of making their own decisions should have their privacy and opinions respected. However people sometimes have difficulty making good decisions for a number of reasons. Not the least of that is that selecting a Medicare Plan can be difficult due to a lot of varying factors. Additionally Medicare is always subject to change. While it is good to respect parental privacy and decisions it does no harm to be informed about Medicare. Having the facts allows you to better assist and discuss Medicare with your folks if needed.
Do This Right Now:
Call 1 800 633-4227 or go to www.medicare.gov and order these two booklets:
Medicare and You (Pub. No. CMS 10050-01)
Choosing a Medigap Policy (Pub. No. CMS 02110)
There is no cost for these very helpful publications.
There are two main components to Medicare:
Part A is Hospital Insurance. Most people do not pay for Part A.
Part B is Medical Insurance. Most people pay a monthly premium for Part B.
If your folks are receiving Social Security, Medicare Part A starts the month of their 65th birthday. Your parent will need to apply for Medicare if they are not receiving Social Security or Railroad Retirement benefits three months prior to turning 65.
If a parent(s) did not pay Medicare taxes while they were working and they are 65 or older they may still be able to buy Part A.
For further information call Social Security at 1 800 772-1213 or go towww.ssa.gov
The Railroad Retirement Board can be reached at 1 800 808-0772.
NOTE: If one of the parents was working and had health plan coverage for part of the year there are Special Enrollment Periods. Contact the Social Security Administration for details.
DO NOT put off enrollment in Medicare. Delays will cost money due to increases due to late enrollment. Part B premiums go up 10% for each 12-month delay in enrollment.
Medicare Part A helps to cover:
NOTE: Medicare Part A helps to pay for these services. It does not cover all expenses.
Part B helps to cover medical and doctors’ services, outpatient care, surgery, tests, medical equipment, therapy and some other services and supplies. Additionally Part B helps cover:
Medicare Part B is not free. Depending on income most people will pay a standard premium amount for Part B but depending on income the amount could be higher. Often this is deducted from a recipients Social Security check. Check your Medicare and You 2011 booklet or the site for details and further information. There are other components to Medicare and prescription drugs that are outlined below.
There are different ways to get Medicare. You/your parents can choose Original Medicare or select a Medicare Advantage Plan which would be a Health Maintenance Organization (HMO) or a Paid Provider Organization (PPO).
With Original Medicareyou get Part A (Hospital Insurance) and Part B (Medical Insurance). You/parents get to choose doctors, hospitals and other providers. Usually you will for deductibles and coinsurance. As well you will likely pay a monthly premium for Part B. With Original Medicare you must join a Medicare Prescription Drug Plan (Part D) that is offered by a Medicare approved private company.
As noted Medicare does not pay for all health care expenses and you may consider buying supplemental coverage like a Medigap policy. These policies are sold by private and can help cover out of pocket costs (gaps) such as co-payments, coinsurance and deductibles. Every Medigap Policy must follow Federal and State consumer protection laws and Medicare insurance companies can sell only a standardized policy identified in most states by the letters A through L.
As mentioned selecting a Medicare Advantage Plan (originally called Medicare + Plus) typically means joining an HMO or PPO. This is Medicare Part C which covers both Part A (Hospital Insurance) and Part B (Medical Insurance). In a Medicare Advantage Plan you need to use plan doctors and hospitals. There is a monthly premium that you/folks pay and a co-payment for services provided. Plans can vary. Most Medicare Advantage Plans include Part D (Prescription drugs) for an additional cost.
You cannot use a Medigap policy if you/folks are using a Medicare Advantage Plan as it will not cover any additional expenses. If your folks already are enrolled in a Medicare Advantage Plan they cannot be sold a Medigap policy. Medicare questions
It is appropriate here to mention some things about the Medicare card. This document will likely play an important part in an older person’s life. Much like a driver’s license, it’s a small but critical document.
The Medicare card number is important for all claims and correspondence that occurs. Mom and Dad will each have their own number. Their Medicare number is their Social Security number usually followed by a letter.
Some things about the Medicare card to keep in mind are:
If your Medicare card is lost or damaged it can be replaced. See Card Replacement
Note: If possible you may want to get your folks Medicare card laminated.
Health care providers are required to notify patients if Medicare will not cover some particular service or procedure. Medicare will only cover services it deems “reasonable and necessary”. If notification is not given and assignment is accepted, the physician may have to absorb those costs.
If there is a disagreement with a Medicare decision, it can be appealed. For a Part A decision, contact the Social Security office. If the amount is over $100, you may request a formal hearing.
For a Part B disagreement, it is advised to first check with the Medicare Carrier and try to solve the problem. It may only require resubmitting the bills. If this does not satisfactorily resolve the issue, it can be appealed to the agency handling the Medicare claim, provided the amount is more than $100.
Health services under Medicare are not free! A percentage and a deductible will have to be paid by the recipient. There is no monthly premium for those who meet Social Security or Railroad Retirement guidelines. Others who are eligible may buy coverage for a monthly premium.
There are different ways to get Medicare. You/your parents can choose Original Medicare or select a Medicare Advantage Plan which would be a Health Maintenance Organization (HMO) or a Paid Provider Organization (PPO).
With Original Medicare you get Part A (Hospital Insurance) and Part B (Medical Insurance). You/parents get to choose doctors, hospitals and other providers. Usually you will for deductibles and coinsurance. As well you will likely pay a monthly premium for Part B. With Original Medicare you must join a Medicare Prescription Drug Plan (Part D) that is offered by a Medicare approved private company.
As noted Medicare does not pay for all health care expenses and you may consider buying supplemental coverage like a Medigap policy. These policies are sold by private and can help cover out of pocket costs (gaps) such as co-payments, coinsurance and deductibles. Every Medigap Policy must follow Federal and State consumer protection laws and Medicare insurance companies can sell only a standardized policy identified in most states by the letters A through L.
As mentioned selecting a Medicare Advantage Plan (originally called Medicare + Plus) typically means joining an HMO or PPO. This is Medicare Part C which covers both Part A (Hospital Insurance) and Part B (Medical Insurance). In a Medicare Advantage Plan you need to use plan doctors and hospitals. There is a monthly premium that you/folks pay and a co-payment for services provided. Plans can vary. Most Medicare Advantage Plans include Part D (Prescription drugs) for an additional cost.
You cannot use a Medigap policy if you/folks are using a Medicare Advantage Plan as it will not cover any additional expenses. If your folks already are enrolled in a Medicare Advantage Plan they cannot be sold a Medigap policy. Medicare questions
It is appropriate here to mention some things about the Medicare card. This document will likely play an important part in an older person’s life. Much like a driver’s license, it’s a small but critical document.
The Medicare card number is important for all claims and correspondence that occurs. Mom and Dad will each have their own number. Their Medicare number is their Social Security number usually followed by a letter.
Some things about the Medicare card to keep in mind are:
Note: If possible you may want to get your folks Medicare card laminated.
Health care providers are required to notify patients if Medicare will not cover some particular service or procedure. Medicare will only cover services it deems “reasonable and necessary”. If notification is not given and assignment is accepted, the physician may have to absorb those costs.
If there is a disagreement with a Medicare decision, it can be appealed. For a Part A decision, contact the Social Security office. If the amount is over $100, you may request a formal hearing.
For a Part B disagreement, it is advised to first check with the Medicare Carrier and try to solve the problem. It may only require resubmitting the bills. If this does not satisfactorily resolve the issue, it can be appealed to the agency handling the Medicare claim, provided the amount is more than $100.
Health services under Medicare are not free! A percentage and a deductible will have to be paid by the recipient. There is no monthly premium for those who meet Social Security or Railroad Retirement guidelines. Others who are eligible may buy coverage for a monthly premium.
Medicare provides for basicmedical coverage and it does not cover all of the expenses involved. There are specific things that Medicare does not cover, or cover completely, under Parts A or B.
NOTE: Refer to the handbook “Medicare & You” for specifics or visit www.medicare.gov
For persons with permanent kidney failure, there are special rules for which one is eligible if that person is receiving maintenance dialysis or a kidney transplant. However, that person must be insured or getting monthly Social Security benefits or be in the Railroad Retirement system, or have worked long enough in the government to be insured for Medicare. There are no age limits.
Under certain conditions a spouse, divorced spouse, widow or widower, a dependent parent upon turning 65 may qualify for hospital insurance based on your work record. Additionally, disabled widows and widowers under age 65 and divorced disabled widows and widowers under 65 and disabled children may be eligible for Medicare, typically after a 24-month qualifying period.
Medicare provides good basic protection against the ever-increasing costs of health care. However, Medicare does not cover all medical expenses, nor extended long-term care. For this reason, it is sometimes a good idea to have Original Medicare supplemented in some manner. There are a number of ways to do this and it is important to be aware if the folks have or need some form of additional coverage.
The discharge planner or social worker at the hospital can be of great assistance. Contact them early in the stay or ahead of time if the course of action has been determined – home or care facility. This gives the planner ample time to prepare the discharge plan. At all times include Mom/Dad in any discussions and plans if they are so able.
Hospital social workers or discharge planners are very knowledgeable about Medicare and will provide information on other kinds of financing and resources.
The social worker or planner will arrange for services when the patient is discharged and ready to go home. They have contacts with home health care services, nursing homes, social service agencies and other resources. This is their job. The more you can help them, the more they can help you.
The planner will need relevant information such as:
Federal law requires hospitals have staff that oversees the care of each patient. This includes a discharge plan that will assist in the transition to home or other care facility. A formal appeal process is available if either you or your parent feels that it is not time to leave the hospital. The discharge planner must provide you with this information or you can contact your local social services office.
If the post hospital care will require daily skilled nursing or rehabilitation services, Medicare Part A will help pay for care in a Medicare participating skilled nursing facility. Skilled nursing care is that care which can only be provided by licensed nursing personnel based upon a doctor’s orders. Skilled rehabilitation would be those services such as physical therapy provided by or under supervision of a professional therapist.
There are five conditions that must be met in order for Medicare to help with the costs:
1. The patient has been in the hospital for at least three days in a row (not counting discharge day, before being admitted to a skilled nursing facility.
2. The condition requires daily skilled nursing or skilled rehabilitation services which can only be provided in a skilled nursing facility.
3. The patient is in the skilled nursing facility for the condition that was treated in the hospital.
4. The patient is admitted to the skilled nursing facility within a short time after discharge from the hospital, usually less than 30 days.
5. The doctor or other medical professional certifies that the patient needs skilled nursing or rehabilitation on a daily basis.
Medicare Part A (Hospital Insurance) will cover most of this for premiums and co-insurance for 2009 check this link: Premiums and Co-Insurance
Medicare Part A does not pay for doctor’s fees while in a skilled nursing facility. Part B covers doctor’s services.
Not all skilled nursing facilities are the same in regard to Medicare. Each will have a level of participation in Medicare. Talk to the hospital discharge planner and the business officer at the skilled nursing facility about the level of participation in Medicare.
A skilled nursing facility participating in Medicare cannot require a deposit or other pre-payment as a condition of admission for services that are covered by Medicare. If your parent is in a skilled nursing facility and the staff decides they no longer need the level of service covered by Medicare, you and/or your parent must be notified immediately. If there is disagreement, the facility must submit your claim to Medicare for a decision. The facility may not require a deposit until Medicare issues a decision. You or your parent will be responsible for any co-insurance and for any services not covered by Medicare.
For more on Skilled Nursing Facilities refer to the HOUSING Chapter. Be sure to order the booklet Medicare Coverage of Skilled Nursing Facility Care (CMS Pub. No. 10153) 1 800 633-4227.
A hospice can be a public agency or private organization engaged primarily in providing pain relief, symptom management and other services to a terminally ill person. Hospice care can either be inpatient care or at home care. Hospice care provides skilled nursing, medication supervision, emotional support and respite. In addition, hospice care can provide training for the family providing care to the terminally ill person whom chooses to stay in their own home.
The Medicare hospice benefit covers most services and allows a hospice to provide appropriate custodial care and counseling services. Medicare Part A will help pay for hospice care providing the following conditions apply:
What are standard Medicare terminal illness benefits? Under the hospice benefit, there are no deductibles to be paid. With the Medicare covered terminal illness, the patient does not pay except for small co-insurance amounts for outpatient drugs and inpatient respite care. The amounts vary in different regions of the country.
Under the hospice inpatient program, respite care is a short term inpatient stay in a facility. Each inpatient respite care stay is limited to five days in a row. This respite provides some short-term relief to those who normally assist with home care.
To locate a hospice program in a particular area, contact the county health department, a hospital social worker, or the National Hospice Organization (NHO).
National Hospice Organization
1901 North Moore Street, Suite 901
Arlington, VA 22209
1 800/658-8898 or www.nho.org
Check the free booklet Medicare Hospice Benefits (CMS Pub. No. 02154).
Part A will pay for no more than 190 days of inpatient care at a participating psychiatric hospital. However, in a general hospital, a person under psychiatric care is not limited to the 190-day limit. For detailed information, contact the Social Security Administration or a professional who works with Medicare.
Tricare or Tricare for Life (TFL) started Oct. 01, 2001 and provides expanded medical coverage for Medicare-eligible retirees, retired guard members and reservists. Certain family members including former spouses are eligible. For more info on TFL call 1 888 DOD-LIFE or go to www.tricare.osd.mil . For additional military retiree benefits, call 1 800 538-9552. You may also find assistance from the Department of Veterans Affairs at www.va.gov. Look at this plan as many regard it highly.
The rising cost of prescription medication for the elderly is a topic of major concern throughout the country. There are many programs that that offer assistance. Go to www.medicare.gov and select “Prescription Drug Assistance Programs” to find what is available in your folks’ area. Libraries, senior centers and other local agencies will be of help. Also check with ELDERCARE at 1 800-677-1116 if your folks live out of state; be sure to have their zip code.
Typically Medicare does not pay for long term care. However private companies sell insurance that will cover medical and non-medical services. For more information get a copy of A Shopper’s Guide to Long-Term Care Insurance from your State Insurance Department. Check the Blue Section of your phone book for local listings. Also check with an employer or Union Health Coverage. Be sure to see this Medicare page for your questions about long term care.
It may be that the folks have an employer group health insurance plan and they are still covered under this plan even though they maybe retired. Or one of your parents could still be working. It is always a good idea for a person to check with an employer, union or service group before retirement regarding benefit packages. Most likely Mom/Dad have planned well. Nonetheless it is always good to do a periodic review of insurance of any kind. Examine the options. Often if one leaves a group employer or union plan they cannot get back on.
The Medicare Medical Savings Account (MSA) Plan first became available in November of 1998 as a test program for 390,000 Medicare beneficiaries. Now these programs help people with limited income and resources save money by paying some or all of the Medicare premiums. Resources are things such as checking/saving accounts stock and bonds. Each state has varying income and qualification levels so check with your state medical assistance office (blue section of phone book) or call Medicare 1 800-633-4227.
Elders with very limited income and resources may qualify for Medicaid. This joint federal/state program covers most or all medical needs. Medicaid came into being by the Social Security Act of 1966 under Title XIX. Medicaid is financed by state and federal taxes and is administered by each individual state under certain federal guidelines. Thus, each state will vary in how its program is run and how services will be paid for.
It is important to contact the appropriate state health agency which administers the Medicaid program in the state in which your folks reside. This can also be checked at www.medicare.gov
or contact the local Area Agency on Aging – Call ELDERCARE 1 800 677-1116 Note: When calling ELDERCARE be sure to the folks Zip Code and city/county/state that they live in.
Every state has its own supplemental programs that can be used to augment Medicare or private health plans. You can get information about these programs at the county departments of social services in which your parent resides.
Program of All-Inclusive Care for the Elderly is for seniors only (55 and up) who live in a PACE area and combines Medicare and Medicaid for elders who are frail enough to meet your States standards for nursing home care. This comprehensive medical and social service can be provided at home, an adult day care and/or inpatient facilities. This allows many seniors to continue living at home while receiving care with plans developed by doctors, nurses and health care professionals. PACE is available in States that offer it with Medicaid. Please see PACE
for more information.
Everyone who receives Medicare is Guaranteed Rights that protect him or her. If you or a parent does not agree with an amount paid for a service or if a service isn’t covered or is stopped, there is a Process for Appeal.
A Medicare recipient has the Right to Information, Emergency Services, the Right to see Doctors, Specialists and participate in decisions as well as knowing what the Treatment Options are.
As well Medicare recipient has the Right to Culturally Competent Services and Nondiscrimination. The Right to File Complaints and the Right to Privacy of Personal and Medical Information are guaranteed.
Learn more about Medicare rights. Order the booklet Your Medicare Right and Protections (CMS Pub. No.10112).
IMPORTANT NOTE: Medicare health plans differ in quality and they vary from area to area. Medicare monitors the quality of programs and this information is available to you and/or your folks. Call 1 800 633-4227 and ask for health plan quality information or go to
www.medicare.gov – select “Medicare Health Plan Compare”.
These are directives that pertain to treatment preferences and the designation of a surrogate decision-maker (such as you) in the event that a person (a parent or other) should become unable to make medical decisions on their own behalf. Advance directives generally fall into three categories: living will, power of attorney and health care proxy.
LIVING WILL: This is a written document that specifies what types of medical treatment are desired. A living will can be very specific or very general.
The most common statement in a living will is to the effect that: “If I suffer an incurable, irreversible illness, disease, or condition and my attending physician determines that my condition is terminal, I direct that life-sustaining measures that would serve only to prolong my dying be withheld or discontinued.
More specific living wills may include information regarding an individual’s desire for such services such as analgesia (pain relief), antibiotics, hydration, feeding, and the use of ventilators or cardiopulmonary resuscitation.
HEALTH CARE PROXY: This is a legal document in which an individual designates another person to make health care decisions if he or she is rendered incapable of making their wishes known. The health care proxy has, in essence, the same rights to request or refuse treatment that the individual would have if capable of making and communicating decisions.
DURABLE POWER OF ATTORNEY: This is the third type of advance directive. Individuals may draft legal documents providing power of attorney to others in the case of incapacitating medical condition. The durable power of attorney allows an individual to make bank transactions, sign Social Security checks, apply for disability, or simply write checks to pay the utility bill while an individual is medically incapacitated.
Something to keep in mind about AMD’s is that they DO NOT have to be for elderly people only. There have been many instances, some that have come to national prominence where a young person has been in a tragic accident or fallen by some disease and they may face the outlook of being on life support systems for years, maybe decades. This then becomes a moral issue that can spill over into the courts in trying to determine how this once healthy young person would want to live out their remaining days since they are incapable of making that decision.
www.firstgov.gov
is a good site to check with access to all on-line U.S. Federal Government resources.
www.healthfinder.gov
can direct you to many Federal agencies, State agencies as well as nonprofit organizations, professional associations and universities with a broad array of health information.
www.ssa.gov
is the official site of the Social Security Administration. Information and services including applying for Social Security Retirement Benefits are available.
www.insurekidsnow.gov
has much health insurance information for working families with children including S-CHIP or State Child Health Insurance Program.
www.consumer.gov
the one-stop federal consumer information site which has info on health and health care quality.
www.hhs.gov
is the official website of the Department of Health and Human Services. Their mission is to protect the health and provide assistance to infants, children, the disabled and older Americans.
www.aoa.gov
The Administration on Aging is a part of the DHHS which provides information to older Americans.
www.aarp.org
is the American Association of Retired Persons who provide advocacy, education, information and other services.
www.seniors.gov
helps seniors conduct online business with federal agencies.
www.va.gov
the Department of Veterans Affairs has information on VA programs, service benefits and lists the VA facilities.
www.eldercare.gov
the ELDERCARE LOCATOR website, funded by HHS. This site allows one to find local, state and federal agencies and services with its search engine.
www.benefitscheckup.org
an online service provided by the National Council on Aging and assists in determining eligibility for public assistance programs for older Americans.
www.leapfroggroup.org
information to help consumers make decisions related to hospital choices.
www.medicinenet.com
medical info on diseases and conditions, symptoms, signs, procedures, tests and medications.
Additional useful sites
www.ec-online.net
There are a number of useful booklets that Medicare provides to help make informed decisions. These booklets may be accessed, read and printed online at www.medicare.gov
(see Publications). You can “Subscribe” to new publications as they become available also.
You may call Medicare to order the booklets sent to you 1-800-633-4227, TTY/TDD: 1-877-486-2048
NOTE: These books are available in English, Spanish, Audiotape, Braille, and Large Print. Some booklets are now available in Chinese.
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Recent Comments: Medicare and Insurance
I think its a big mess. Medicare, the whole health care industry needs to be overhauled but how do...Posted Sep 28, 2011
Thank you for all of the fantastic information you provided. My mother is dealing with dementia. In fact my whole...Posted Aug 21, 2011