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Aging & Elder Care - Understanding Medicare

February 9, 2014
By GLYNIS VALENTI - Staff Writer (gvalenti@timesleaderonline.com) , Times Leader

"A man's health can be judged by which he takes two at a time - pills or stairs."-Joan Welsh

As one ages, the likelihood of a hospital stay or, at the very least, regular medical care increases. Spouses or other immediate family members often become caregivers, and it is important to realize that it may mean a certain amount of advocacy, too. The coming paragraphs will lay out the very basics in Medicare-eze to help navigate that insurance realm.

Medicare is a national socialized insurance created by President Lyndon B. Johnson as part of The Great Society plan. It was signed into law under the Social Security Act of 1965. At the time, it allowed any United States citizen over 65 years of age, regardless of income or health history, to see participating doctors. Until Medicare, people purchased private insurance, and companies charged higher premiums or denied coverage as clients aged. The government stepped in because so many elderly could not afford medical treatment. The program has added several provisions throughout its five decades including those for disability insurance for younger clients, for health maintenance organizations (HMOs), and for prescription drug coverage. The patient must be living in the United States. There are four "parts" to Medicare. Parts A and B together are called Original Medicare.

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According to medicare.gov, Medicare Part B (Medical Insurance) covers medical nutrition therapy services and certain related services. A registered dietician or nutrition professional who meets certain requirements can provide these services, which may include nutritional assessment, one-on-one counseling, and therapy services through an interactive telecommunications system.

Part A is hospital insurance. Most people do not have to pay if they or their spouses have worked and paid Medicare taxes, and those who are collecting Social Security are automatically enrolled in Part A at age 65. There is, however, a penalty for late enrollment if one doesn't sign up once eligible. Part A helps cover costs of inpatient care in hospitals, inpatient care that is not considered custodial or long-term in a skilled nursing facility, hospice care and home health care. This care would include a semi-private room, nursing care, hospital supplies and meals. Medicare will also pay for inpatient care in a religious non-medical health care institution where religious beliefs prohibit medical treatments, but will only cover room and board or other non-medical services.

Part B is medical insurance and helps with necessary doctors' services, outpatient care, home health services and medical equipment. It also pays for preventive services such as tests and screenings and vaccinations, for example glaucoma tests, mammograms, colorectal and prostate cancer screenings, bone density screenings, cardiovascular disease screenings, diabetes screenings, flu shots, depression screenings, HIV screenings and a yearly "wellness" visit.

This coverage is voluntary, and there is a monthly premium, usually taken out of the Social Security or Railroad Retirement Board monthly benefit checks automatically. In 2013, the standard premium was $104.90, but this may vary based on income, and Social Security will notify the recipient of any change from the standard charge. As with Part A, there is an enrollment window of time, and the penalty for late sign-up is an additional 10 percent of the premium for each year's delay.

Services that are not covered by Original Medicare (Parts A plus B) include routine dental or vision care - including eyeglasses and dentures - hearing exams and hearing aids, cosmetic surgery, acupuncture and long-term care.

Medicare Part C, called Medicare Advantage, is health insurance with both Part A hospital and Part B medical coverage but is administered through certain providers. Patients must choose an HMO (health maintenance organization) or PPO (preferred provider organization) that will handle all medical care through Medicare-approved private insurance companies. Systems like Humana, UnitedHealthcare or The Health Plan may charge monthly premiums from $2 to almost $200, depending on the plan, and the patient will also pay for Part B coverage.

There are many cost and service variables in Part C because there are so many insurance company and provider options. While in Original Medicare the doctor or service provider need only "accept assignment" to treat Medicare patients, Medicare Advantage patients must go to facilities or doctors in the designated network or the patient could be liable for full, out-of-pocket costs.

Prescription drug coverage is handled under Medicare Part D. This, like Part B, is optional and available under both Original Medicare and Medicare Advantage. "Prescription Drug Plans" (PDPs) are run by Medicare-approved insurance companies or prescription drug services and are somewhat localized, meaning that some plans are only relevant for specific areas. There is usually a yearly deductible that, again, is different for each plan.

Original Medicare patients can choose their preferred service. Advantage patients may have drug coverage included with their plans. If an Advantage patient with drug coverage signs up for a Part D Prescription Drug Plan, the patient will be dropped from the Advantage insurance and enrolled in Original Medicare, so it is good to be thoroughly familiar with the provisions of the Advantage plans.

With all of these Parts, there will still be out-of-pocket charges such as copayments for office visits, coinsurance premiums and deductibles. To help with these costs, seniors can purchase a Medicare Supplement Insurance plan: Medigap. The plans, labeled "A" through "N" offer varying coverage for components of Original Medicare. For instance, all of the Medigap plans cover 100 percent of Medicare Part A coinsurance and hospital costs up to 365 days after Medicare benefits are used. However, only plans "C" and "F" will pay 100 percent of the Part B deductible.

Those interested in purchasing Medigap should first determine how many components of Part A and B coverage are routinely used. Once a patient decides that, say, plan "D" would be most applicable and he can compare costs and coverage among available insurance carriers in his area. While all of the plans are designed as a standardized offering (i.e. plan "A" must offer a minimum of a specific set of benefits regardless of the carrier), some plans have additional benefits in comparison.

Here are a few personal observations and notes for caregivers or adult children based on this writer's experience.

A Medicare agency will send out periodic statements of doctor visits, hospital stays, prescriptions and other invoices charged to Medicare. Sometimes these are several pages long, especially if the patient has been involved in an accident or had surgery. If possible, match any invoices the patient has received with these statements to make sure there are no errors in information or charges. It may take several weeks to reflect all of the payments by Medicare and insurance companies.

A patient can be released from the hospital to a nursing facility for "rehabilitation and physical therapy." Medicare will pay the expenses for up to 100 days of "skilled nursing" at the facility if the hospital stay is at least three days. The physical therapist and or doctors will determine through a goal and evaluation process how long the patient remains in "skilled" care. As long as the patient progresses and participates, the skilled period is in effect. When the patient reaches said goals, he will be responsible for the day charges at the facility and can be released from their care. At this point, many patients or their designated Powers of Attorney apply for Medicaid to assist with long-term care expenses in connection with medical conditions.

Medicare will pay for medical equipment like wheelchairs, walkers, neck braces or oxygen as long as the doctor prescribes the equipment as medically necessary.

Regarding automatic refill prescriptions, caregivers should try to monitor the filling dates against the number of pills prescribed. This writer found entire bottles of pills untouched, yet the prescription service called for pick-ups continually. Other prescriptions would be down to the last couple of pills, and her father would have to call the service for a new bottle.

Seniors don't always remember the previous pick-up date. If they are taking their medications as prescribed, there should be no lapses and no overages with the prescriptions. When this writer tried to explain the discrepancies to her elderly, ailing father, he insisted that the service was on a schedule that told them when to refill. After both of her parents were admitted to a nursing home, she had to dispose of what represented hundreds of dollars worth of co-pays that were either partial or whole bottles, some still in drug store bags.

Should a caregiver or adult child want or need to discuss a patient's Medicare benefits with a Medicare representative, he or she will need to have written permission on file with Medicare, or the patient will need to verbally grant that permission over the phone to a representative when the child calls. It is best to have this permission on file before the Medicare beneficiary becomes incapacitated.

Toward the end of each year, Medicare mails a handbook called "Medicare & You" to beneficiaries. It is an in-depth description of the program and application process with updates for the coming year. The book is tailored to each state, and available Medicare-approved health plans and prescription drug programs are listed, making it easy for caregivers and adult children to understand the extent of the seniors' coverage. For even more detail and any questions, visit www.medicare.gov or call 1-800-633-4227 (1-800-MEDICARE).

 
 

 

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