All posts by Angela Scott

Karen Telleen-Lawton: Medicare: Three Truths And a Lie – Noozhawk

By Karen Telleen-Lawton, Noozhawk Columnist | June 17, 2019 | 4:00 p.m.

As my cohort enters the Medicare system, misconceptions about senior public health insurance spread through social media. At a gathering of a few friends the other day, I decided to challenge them with a Medicare “3 truths and a lie” quiz.

See if you can discern the myth among these truths before reading the discussion that follows.

» You need to “check in” with Medicare when you turn 65, even if you’re still covered by a plan at work.
» If you choose Medicare Advantage, you have a limited time to change your mind and choose Medigap.
» Medicare covers vision and dental costs.
» Medicare is going bankrupt.

A few months before you turn 65, it is essential to contact Medicare, even if you’re still covered by a plan at work. This is because you are required to have at least as good medical insurance coverage as Medicare provides.

If you find out after the fact that your company coverage was inferior to Medicare, you’ll pay higher Medicare rates (forever) when you join.

Workers at companies with 20 or more employees are entitled to stay on their company insurance. Small companies are allowed to drop you: another reason to understand your situation as you approach 65.

It is also true that Medigap’s no-strings-attached offer is limited. Your main options when you join Medicare are among basic (Part A, Part B and Part D), Medicare Advantage (usually including A and B and sometimes D), or Medicare plus Medigap (also called “supplemental insurance”).

Each part of Medicare has associated costs: monthly premiums, deductibles and co-pays.

Choosing either Medicare Advantage or Medigap helps to make your costs more predictable. MA accomplishes this through Health Maintenance Organization (HMO-type model), which requires you to use in-network services except in rare circumstances.

Medigap allows flexibility in choosing your own doctors and, depending on your plan, you may be covered for international travel.

The catch for Medigap is there are only certain times when you can choose it without regard to pre-existing conditions. The times you can freely choose Medigap with full federal protections are:

» The first time you enroll in Medicare.
» Within the first 12 months of Medicare.
» If you joined Medicare Advantage less than 12 months ago.
» If you joined MA more than a year ago, but the MA situation changes, such as they stop providing service here, or you move, or you were misled.

The third statement, about vision and dental coverage, is false. Basic Medicare does not cover vision and dental. This is a rude awakening for some seniors, particularly those who had been putting off getting hearing aids until they were 65.

However, vision and dental coverage are provided in some Medicare Advantage plans. They typically provide two dental cleanings per year, plus glasses, contacts, hearing aids and exams.

According to senior65.com, “While Medigap will cover cataract surgery costs, or serious vision issues, most vision care (eye exams, glasses, contacts) is not covered by Medigap. For routine care, you can get a stand-alone vision plan.”

Finally, the rules for Medicare financing need tweaking, but it is far from bankrupt.

Our FICA payroll taxes support both Social Security and Medicare. Both programs have built up trust funds since inception.

However, with the increasing cost of care, the influx of 10,000 Baby Boomers a day, and expanded services over the years, the Medicare surplus is estimated to dry up in 2026 if no changes are made. After that, current taxes would support payments on 89 percent.

Know the facts, and make your voice heard to keep Medicare solvent.

— Karen Telleen-Lawton serves seniors and pre-seniors as the principal of Decisive Path Fee-Only Financial Advisory in Santa Barbara. You can reach her with your financial planning questions at [email protected]. Click here to read previous columns. The opinions expressed are her own.

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CMA Alert – June 13, 2019

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  1. The National Association of Insurance Commissioners Recognizes Maintenance Therapy, Bolstering the Jimmo Settlement Agreement
  2. Inadequate Personal Care at Home Increases Overall Medicare Costs
  3. The New York Times Reports On HUD-Backed Nursing Homes
  4. Center for Medicare Advocacy Submits Comments to House Ways & Means and Energy & Commerce Committees on Draft Part D Legislation

The National Association of Insurance Commissioners Recognizes Maintenance Therapy, Bolstering the Jimmo Settlement Agreement

The National Association of Insurance Commissioners (NAIC) is a standard-setting and regulatory support organization governed by chief insurance regulators from across the country. NAIC’s website indicates that organizational members and its resources, “form the national system of state-based insurance regulation in the U.S.” One such resource is NAIC’s Glossary of Health Insurance and Medical Terms, which defines ‘rehabilitation’ as follows:

Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings (emphasis added).

NAIC’s definition recognizes that rehabilitation services may not only be necessary to improve a patient’s condition but may also be necessary to “keep” his or her skills and functioning. This definition confirms the Settlement Agreement in the nationwide class-action lawsuit Jimmo v. Sebelius, No. 5:11-CV17 (D. VT).

Approved by a federal district court in January 2013, the Jimmo Settlement required the Centers for Medicare & Medicaid Services (CMS) to confirm that Medicare coverage of skilled nursing and/or therapy services is determined by a beneficiary’s need for skilled care, not on a beneficiary’s potential for improvement. As a result, Medicare policy now clearly states that coverage:

[D]oes not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care. Skilled care may be necessary to improve a patient’s condition, to maintain a patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.[1]

Bolstering NAIC’s recognition of maintenance care, the Jimmo Settlement means that Medicare beneficiaries must not be denied coverage for maintenance nursing or therapy provided by a skilled nursing facility, home health agency, or outpatient therapy provider when skilled personnel must provide or supervise the care in order for it to be safe and effective. Medicare coverage should not be denied solely because an individual has an underlying condition that won’t get better, such as MS, ALS, Parkinson’s disease, or paralysis.

If Medicare coverage is denied based on an erroneous “Improvement Standard,” please visit the Center’s Improvement Standard and Jimmo News webpage for our setting-specific self-help materials. Although challenging a Medicare denial may seem daunting, beneficiaries and their representatives can win appeals when equipped with the right information.

_________________

[1] CMS Transmittal 179, Pub 100-02, 1/14/2014; See also Medicare Benefit Policy Manual (MBPM), Chapter 7 – Home Health Services, Section 20.1.2, 40.1-.2; MBPM, Chapter 8 – Coverage of Extended Care (SNF) Services Under Hospital Insurance, Sections 30.2-.4; MBPM, Chapter 15 – Covered Medical and Other Health Services, Sections 220, 220.2-.3, 230.1.2.

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Inadequate Personal Care at Home Increases Overall Medicare Costs

Medicare home health coverage plays a vital role in supporting the health, safety, and well-being of adults in need of community-based care. Unfortunately, the Center for Medicare Advocacy (the Center) regularly hears from Medicare beneficiaries and their families about their inability to access care, or the appropriate amount of care, despite meeting the necessary coverage criteria. For instance, while Medicare authorizes personal hands-on care (such as assistance with toileting and ambulation), access to home health aides continues to shrink. Not surprisingly, the failure to provide adequate care to beneficiaries in the community is increasing overall Medicare costs.

According to a recently published study in the Annals of Internal Medicine, poor support in the activities of daily living negatively affects annual Medicare spending. The May 2019 study, entitled “Medicare Spending and the Adequacy of Support With Daily Activities in Community-Living Older Adults With Disability: An Observational Study,” finds that poor support for “mobility and self-care is associated with higher Medicare spending, especially in the middle and lower ends of the spending distribution.” In a post on The Commonwealth Fund’s website, the authors suggest, “more than $4 billion in additional spending may have been incurred by Medicare in 2015 as a result of excess costs related to inadequate support . . . .” The authors note that more than one in five beneficiaries reported negative outcomes because of inadequate support, including difficulty toileting, problems with ambulation, and medication errors.

As our Medicare Platform states, the Center is committed to reducing ongoing barriers to care by ensuring home health coverage for beneficiaries who meet the necessary coverage criteria, as well as ensuring beneficiaries have access to legally authorized home health aides. To learn more about our efforts to protect and improve the home health benefit, please visit our Home Health Care webpage at https://www.medicareadvocacy.org/medicare-info/home-health-care/.

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The New York Times Reports On HUD-Backed Nursing Homes

           

Nursing home financial arrangements are important issues of public policy. Failures by state and federal governments to ensure nursing home financial accountability and integrity have an increasingly devastating impact on nursing home residents and their families across the country.

According to a recent report by The New York Times, the U.S. Department of Housing and Urban Development (HUD) administers a government-backed mortgage program for residential care facilities. Under what is known as a Section 232 loan agreement, HUD has the authority to guarantee bank loans made to nursing homes for the purposes of purchasing, refinancing, constructing, or substantially rehabilitating a facility. However, the financial guarantee is not without conditions. Nursing home owners must adhere to certain requirements, such as reporting problematic surveys and fines, as well as working with HUD to establish an action plan for removing a nursing home from the Special Focus Facility list.

The Times reports that the program currently guarantees $20 billion in mortgages for 2,300 nursing homes—or about 15 percent of nursing homes nationwide. The Times’ analysis shows that these nursing homes are “more likely to receive one-or-two-star ratings from Medicare than other nursing homes.” Unfortunately, The Times also notes that, “[b]y the government’s own admission, the federal agency’s stewardship of the program has been haphazard.” Reports on the program spanning several decades indicate poor oversight. For example, The Times identifies a 1995 Government Accountability Office (GAO) report which documents that staff do not focus on “nursing home loans unless financial trouble appears imminent or a default occurs.” The Times also points to a recent report by the HUD Inspector General finding that HUD failed to “penalize operators that did not submit accurate and complete data in a timely manner.”

As The Times’ report highlights, the recent collapse of a Chicago-based nursing home operator demonstrates the program’s problems. The owners stopped making payments on the mortgage of “their crown jewel, the Rosewood Care Centers, barely a year after buying it in 2013 . . . some money meant for the 13 nursing homes and assisted-living facilities went to prop up another investment.” Ultimately, the business defaulted on $146 million in HUD-backed loans in 2018—the biggest failure in the history of the program. The Times adds that, in addition to covering the defaulted mortgages, HUD has spent $15 million since August 2018 keeping the facilities operating.

Consumers deserve transparency and quality. When nursing homes depend on public funds through HUD, the public, in turn, has the right to expect that the nursing homes will use the funds appropriately and provide care that meets federal standards. The Section 232 program needs greater transparency and recognition of quality standards. The Center for Medicare Advocacy and the Long Term Care Community Coalition hope to work with HUD to ensure that the government holds nursing homes accountable for both taxpayer funds and resident care.


For additional information about Medicare and nursing home care,
please visit www.MedicareAdvocacy.org & www.NursingHome411.org

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Center for Medicare Advocacy Submits Comments to House Ways & Means and Energy & Commerce Committees on Draft Part D Legislation

On May 23, 2019, Ways & Means Committee Chairman Richard E. Neal (D-MA) and Energy & Commerce Committee Chairman Frank Pallone, Jr. (D-NJ), along with Ranking Members Kevin Brady (R-TX) and Greg Walden (R-OR) announced a solicitation for comments on draft legislation to reform the Medicare Part D program that would establish an out-of-pocket cap for Medicare beneficiaries.

Drafted in collaboration with other beneficiary-focused organizations, the Center for Medicare Advocacy submitted comments to the committees (all of the submitted comments, along with the committees’ solicitation, are available here).

In our comments, the Center supported adding an out-of-pocket cap in the Part D benefit at a level that will provide meaningful relief for individuals.   We also suggested improving the Part D Low-Income Subsidy (LIS), or Extra Help, by eliminating the asset test and expanding eligibility and eliminating cost-sharing for generic drugs for those with LIS.  We also recommended fixing the flaws in the current Part D exceptions and appeals process, including requiring plans to issue individually-tailored notices at the pharmacy counter when a drug is denied, and allowing such a denial to trigger an appeal right (instead of requiring an individual to follow up with his or her plan in order to request a coverage determination that could then trigger an appeal right).   We also urged the committees to consider allowing tiering exceptions for drugs placed in plans’ specialty tiers, as well as allowing the current, more consumer-friendly off-label drug use standards in Part B to apply to off-label coverage for Part D drugs.

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The Center for Medicare Advocacy is a non-profit organization.
Your contributions to the Center are essential to maintaining our ability to advance access
to comprehensive Medicare coverage and quality health care.


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The New York Times Reports On HUD-Backed Nursing Homes

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Nursing home financial arrangements are important issues of public policy. Failures by state and federal governments to ensure nursing home financial accountability and integrity have an increasingly devastating impact on nursing home residents and their families across the country.

According to a recent report by The New York Times, the U.S. Department of Housing and Urban Development (HUD) administers a government-backed mortgage program for residential care facilities. Under what is known as a Section 232 loan agreement, HUD has the authority to guarantee bank loans made to nursing homes for the purposes of purchasing, refinancing, constructing, or substantially rehabilitating a facility. However, the financial guarantee is not without conditions. Nursing home owners must adhere to certain requirements, such as reporting problematic surveys and fines, as well as working with HUD to establish an action plan for removing a nursing home from the Special Focus Facility list.

The Times reports that the program currently guarantees $20 billion in mortgages for 2,300 nursing homes—or about 15 percent of nursing homes nationwide. The Times’ analysis shows that these nursing homes are “more likely to receive one-or-two-star ratings from Medicare than other nursing homes.” Unfortunately, The Times also notes that, “[b]y the government’s own admission, the federal agency’s stewardship of the program has been haphazard.” Reports on the program spanning several decades indicate poor oversight. For example, The Times identifies a 1995 Government Accountability Office (GAO) report which documents that staff do not focus on “nursing home loans unless financial trouble appears imminent or a default occurs.” The Times also points to a recent report by the HUD Inspector General finding that HUD failed to “penalize operators that did not submit accurate and complete data in a timely manner.”

As The Times’ report highlights, the recent collapse of a Chicago-based nursing home operator demonstrates the program’s problems. The owners stopped making payments on the mortgage of “their crown jewel, the Rosewood Care Centers, barely a year after buying it in 2013 . . . some money meant for the 13 nursing homes and assisted-living facilities went to prop up another investment.” Ultimately, the business defaulted on $146 million in HUD-backed loans in 2018—the biggest failure in the history of the program. The Times adds that, in addition to covering the defaulted mortgages, HUD has spent $15 million since August 2018 keeping the facilities operating.

Consumers deserve transparency and quality. When nursing homes depend on public funds through HUD, the public, in turn, has the right to expect that the nursing homes will use the funds appropriately and provide care that meets federal standards. The Section 232 program needs greater transparency and recognition of quality standards. The Center for Medicare Advocacy and the Long Term Care Community Coalition hope to work with HUD to ensure that the government holds nursing homes accountable for both taxpayer funds and resident care.


For additional information and resources, please visit
www.nursinghome411.org and www.medicareadvocacy.org.

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Center for Medicare Advocacy Submits Comments to House Ways & Means and Energy & Commerce Committees on Draft Part D Legislation

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On May 23, 2019, Ways & Means Committee Chairman Richard E. Neal (D-MA) and Energy & Commerce Committee Chairman Frank Pallone, Jr. (D-NJ), along with Ranking Members Kevin Brady (R-TX) and Greg Walden (R-OR) announced a solicitation for comments on draft legislation to reform the Medicare Part D program that would establish an out-of-pocket cap for Medicare beneficiaries.

Drafted in collaboration with other beneficiary-focused organizations, the Center for Medicare Advocacy submitted comments to the committees (all of the submitted comments, along with the committees’ solicitation, are available here).

In our comments, the Center supported adding an out-of-pocket cap in the Part D benefit at a level that will provide meaningful relief for individuals.   We also suggested improving the Part D Low-Income Subsidy (LIS), or Extra Help, by eliminating the asset test and expanding eligibility and eliminating cost-sharing for generic drugs for those with LIS.  We also recommended fixing the flaws in the current Part D exceptions and appeals process, including requiring plans to issue individually-tailored notices at the pharmacy counter when a drug is denied, and allowing such a denial to trigger an appeal right (instead of requiring an individual to follow up with his or her plan in order to request a coverage determination that could then trigger an appeal right).   We also urged the committees to consider allowing tiering exceptions for drugs placed in plans’ specialty tiers, as well as allowing the current, more consumer-friendly off-label drug use standards in Part B to apply to off-label coverage for Part D drugs.

June 13, 2019 – D. Lipschutz

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Inadequate Personal Care at Home Increases Overall Medicare Costs

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Medicare home health coverage plays a vital role in supporting the health, safety, and well-being of adults in need of community-based care. Unfortunately, the Center for Medicare Advocacy (the Center) regularly hears from Medicare beneficiaries and their families about their inability to access care, or the appropriate amount of care, despite meeting the necessary coverage criteria. For instance, while Medicare authorizes personal hands-on care (such as assistance with toileting and ambulation), access to home health aides continues to shrink. Not surprisingly, the failure to provide adequate care to beneficiaries in the community is increasing overall Medicare costs.

According to a recently published study in the Annals of Internal Medicine, poor support in the activities of daily living negatively affects annual Medicare spending. The May 2019 study, entitled “Medicare Spending and the Adequacy of Support With Daily Activities in Community-Living Older Adults With Disability: An Observational Study,” finds that poor support for “mobility and self-care is associated with higher Medicare spending, especially in the middle and lower ends of the spending distribution.” In a post on The Commonwealth Fund’s website, the authors suggest, “more than $4 billion in additional spending may have been incurred by Medicare in 2015 as a result of excess costs related to inadequate support . . . .” The authors note that more than one in five beneficiaries reported negative outcomes because of inadequate support, including difficulty toileting, problems with ambulation, and medication errors.

As our Medicare Platform states, the Center is committed to reducing ongoing barriers to care by ensuring home health coverage for beneficiaries who meet the necessary coverage criteria, as well as ensuring beneficiaries have access to legally authorized home health aides. To learn more about our efforts to protect and improve the home health benefit, please visit our Home Health Care webpage at https://www.medicareadvocacy.org/medicare-info/home-health-care/.

June 13, 2019 – D. Valanejad

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The National Association of Insurance Commissioners Recognizes Maintenance Therapy, Bolstering the Jimmo Settlement Agreement

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The National Association of Insurance Commissioners (NAIC) is a standard-setting and regulatory support organization governed by chief insurance regulators from across the country. NAIC’s website indicates that organizational members and its resources, “form the national system of state-based insurance regulation in the U.S.” One such resource is NAIC’s Glossary of Health Insurance and Medical Terms, which defines ‘rehabilitation’ as follows:

Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings (emphasis added).

NAIC’s definition recognizes that rehabilitation services may not only be necessary to improve a patient’s condition but may also be necessary to “keep” his or her skills and functioning. This definition confirms the Settlement Agreement in the nationwide class-action lawsuit Jimmo v. Sebelius, No. 5:11-CV17 (D. VT).

Approved by a federal district court in January 2013, the Jimmo Settlement required the Centers for Medicare & Medicaid Services (CMS) to confirm that Medicare coverage of skilled nursing and/or therapy services is determined by a beneficiary’s need for skilled care, not on a beneficiary’s potential for improvement. As a result, Medicare policy now clearly states that coverage:

[D]oes not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care. Skilled care may be necessary to improve a patient’s condition, to maintain a patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.[1]

Bolstering NAIC’s recognition of maintenance care, the Jimmo Settlement means that Medicare beneficiaries must not be denied coverage for maintenance nursing or therapy provided by a skilled nursing facility, home health agency, or outpatient therapy provider when skilled personnel must provide or supervise the care in order for it to be safe and effective. Medicare coverage should not be denied solely because an individual has an underlying condition that won’t get better, such as MS, ALS, Parkinson’s disease, or paralysis.

If Medicare coverage is denied based on an erroneous “Improvement Standard,” please visit the Center’s Improvement Standard and Jimmo News webpage for our setting-specific self-help materials. Although challenging a Medicare denial may seem daunting, beneficiaries and their representatives can win appeals when equipped with the right information.

June 13, 2019 – D. Valanejad

__________________

[1] CMS Transmittal 179, Pub 100-02, 1/14/2014; See also Medicare Benefit Policy Manual (MBPM), Chapter 7 – Home Health Services, Section 20.1.2, 40.1-.2; MBPM, Chapter 8 – Coverage of Extended Care (SNF) Services Under Hospital Insurance, Sections 30.2-.4; MBPM, Chapter 15 – Covered Medical and Other Health Services, Sections 220, 220.2-.3, 230.1.2.

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Special Focus Facility Candidates Must Be Identified On Nursing Home Compare

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Every month, the Centers for Medicare & Medicaid Services (CMS) identifies nursing homes with an extremely poor record of resident care for inclusion in the Special Focus Facility (SFF) program. This program is a federally mandated initiative to address persistent problems through enhanced oversight. Over an 18 to 24-month period, CMS expects SFFs to significantly improve quality of care and implement practices to ensure that poor performance does not reoccur. Facilities that succeed graduate from the program. Facilities that do not face termination from participating in Medicare and Medicaid. Termination from Medicare and Medicaid typically results in a facility’s closure.

While there are many nursing homes with persistent, serious problems, CMS presently limits the SFF program to just 88 facilities nationwide. A June 2019 report by U.S. Senators Bob Casey and Pat Toomey, entitled Families’ and Residents’ Right to Know: Uncovering Poor Care in America’s Nursing Homes, found that an additional 2.5 percent of all certified nursing homes (about 400 facilities) are identified as SFF candidates by CMS based on their “persistent record of poor care.” CMS does not select these facilities to participate because it limits the resources dedicated to the SFF program. The report notes, “[a]s a result, individuals and families making decisions about nursing home care for themselves or for a loved one are unlikely to be aware of these candidates.”

With the publication of the report, Senators Casey and Toomey released the names of the April 2019 SFF candidates. The Senators state that they would work with CMS to make future lists public. Days after the report’s release, Dr. Kate Goodrich (Director, Center for Clinical Standards and Quality and CMS Chief Medical Officer) issued a statement noting that CMS is committed to posting the list of SFF candidates moving forward. However, she gave no indication as to when and where CMS will begin posting the list. Dr. Goodrich’s statement adds, “CMS urges all Americans to consult their physician, family, and Nursing Home Compare before choosing a nursing home for their loved ones.”

Our organizations respectfully urge CMS to prominently identify when a nursing home is a SFF candidate on the facility’s Nursing Home Compare page. As Dr. Goodrich’s statement acknowledges, Nursing Home Compare is the premier resource seniors and families use when choosing a nursing home. Thus, it is essential that the website provide the best information possible about a facility’s safety record. Given that SFF candidates have comparable quality and safety concerns— and are only absent from the SFF list due to a lack of resources allocated to provide for enhanced oversight—it is unconscionable not to properly alert the public when a facility has been identified as meeting the SFF criteria. In fact, if anything, it is more important for people to know when a facility is an SFF candidate, since those facilities are not receiving the enhanced oversight that SFFs in the program are undergoing.


For additional information and resources, please visit
www.nursinghome411.org and www.medicareadvocacy.org.

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A Top House Democrat Mulls A Medigap Long-Term Care Benefit – Forbes

House Ways & Means Committee Chair Richard Neal (D-MA) is mulling a plan to add a limited long-term care benefit to Medicare Supplement (Medigap) insurance. Minnesota proposed a similar plan last year. And the idea would expand to traditional Medicare a recent innovation that added limited supports and services to Medicare Advantage managed care plans.

Neal is the second key House committee chairman to express interest in a new long-term care insurance benefit. Last year, Rep. Frank Pallone (D-NJ), who now chairs the House Energy & Commerce Committee, proposed a public catastrophic long-term care insurance program. The two panels share jurisdiction over long-term care.

Though their ideas are very different, the take-away is that two powerful House committee chairs are interested in creating a federal long-term care benefit of some kind.

Asking for advice

Separately, the Trump Administration is quietly exploring whether it wants to recommend ways to enhance private long-term care insurance, though it is unlikely to propose anything as expansive as Neal’s idea.

While Pallone proposed a working draft of a bill (though it excluded any financing mechanism), Neal is being even more cautious. Rather than making a proposal, Neal made his interest public by releasing a June 3 letter to the president of the National Association of Insurance Commissioners (NAIC). In it, he asked for comments on the concept of a Medigap long-term supports and services (LTSS) benefit.

Medigap policies are offered by private health insurers to top up traditional Medicare. For an additional premium, they cover out-of-pocket deductibles or copays that Medicare Parts A & B do not and sometimes offer additional benefits. Medigap policies are designated by letter (A-N). No matter the insurer, each letter-designated policy has identical benefits, though the premiums vary by carrier.

Competing with Medicare Advantage

Premiums vary by location and plan design but can range from about $70 to $450 per month. Currently, none offer any supports and services such as non-emergency transportation, adult day, home-delivered meals, or nursing home care. Currently, traditional Medicare does not pay for any of these benefits.

However, starting this year, the government allowed Medicare Advantage (MA) managed care plans to include some of these services in their benefit packages. The program started slowly with only about 200 plans but it is expected to pick up in 2020. Plans have just submitted their 2020 benefit packages to Medicare for approval.

Some advocacy and consumer groups have objected to the MA initiative because they say it will drive older adults to enroll in MA rather than traditional Medicare. Currently about one-third of Medicare beneficiaries are in MA plans. The advocates want to see supports and services offered to all Medicare beneficiaries.

That is what Neal seems to have in mind.

What would it cost?

His letter asks the NAIC for advice on how to design a cost-effective LTSS Medigap benefit. He wants to know how to design a benefit, who is likely to participate, and how much such a benefit is likely to cost. Neal asks whether it should be mandatory in all Medigap policies or offered as an optional rider. He also asks whether an optional benefit would create an adverse selection problem that could make policies unaffordable. Hint: The answer to that last question is, “yes.”

Actuaries who helped design Minnesota’s plan calculated that a one-year, $100-a-day home care benefit (effectively a maximum benefit of $36,500) would add about $21 to a monthly Medigap premium. No insurers are yet offering the plans in Minnesota.

Neal’s idea of a limited front-end benefit is similar to the law recently passed in Washington State. However, the Washington measure is a state-only public benefit that is funded through a payroll tax surcharge. It is not linked to Medicare—indeed it could not be without a major change in federal law.

Getting traction

By contrast, Neal seems to be thinking very differently than Pallone, who proposed a universal catastrophic benefit. Instead of a limited front-end benefit that would be triggered as soon as someone needed assistance with daily activities (the Washington State model that Neal seems interested in), Pallone would provide a lifetime benefit of $100-a-day. But only after someone funded their own care needs for an average of about two years.

These days, Pallone seems more focused on broader health care issues than long-term care. And Neal seems to be in the very early stages of exploring a long-term care plan.

But both lawmakers, and even senior member of the Trump Administration, seem to have figured out that long-term care financing is a critical issue for tens of millions of American families. And, just perhaps, it is something they want to address.

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What You Need to Know About Turning 65 and Medigap Plans by Laura Sedlacek – Caldwell Journal


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LENOIR, NC (June 10, 2019) — Here is another very helpful article about healthcare.

What Are My Options if I’m Turning 65 But I’m Already on Medicare A&B?

Usually someone is turning 65 when they go on Medicare A and B for the first time.  But sometimes, if someone has become disabled and has been on Social Security Disability for 2 years, they may then be put on Medicare A and B when they are under 65 after that 2-year period is met.  There are limited options for a Medigap type coverage plan when one is under 65, but there are some products available.  Turning 65, however, opens up some more Medigap type choices.

When you are on Medicare A and B, but under 65, did you know that turning 65 is another open enrollment or qualifying event type situation for you? 

Yes, it is.  You can, in most cases, continue your under 65 Medigap coverage with your current carrier, but sometimes it is in your best interest to switch to a different plan option and/or insurance carrier as well.  Switching doesn’t involve underwriting because for a Medigap plan turning 65 still means Open Enrollment and no health questions.  For other types of Medicare plans, there may be a health question to answer.  It can save you a lot of money to explore your choices when under 65 and getting ready to turn 65 if you are already on Medicare A and B.

Confusing?  It can be.  So, seek out a Medigap specialist to provide you with more information and your choices for when you turn 65.

Bush and Associates insurance has been offering Medigap products to the Unifour area since 1980.  They are experts in Senior coverage options offering Medicare Supplements, Under 65 Medicare Supplements, Other Medicare Products, Vision, Dental, Cancer plans, Life and Long-Term Care.  Get in touch with them today for more information or a free, no obligation quote.

~Bush and Associates, 916 Wilkesboro Blvd. Lenoir, (828) 754-2601, quotes@bushandassociates.net, www.mynchealthplan.com

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Considering basic Medicare with no backup insurance? That could be a costly mistake, experts say – CNBC

If you’re thinking about having basic Medicare without any supplemental coverage, experts have a message for you: Don’t.

With deductibles, copays, coinsurance and — this is a biggie — no out-of-pocket maximum, the program has a variety of costs that make having no backup insurance a huge financial risk.

“All it takes is one big hospital stay and you could be out tens of thousands of dollars,” said certified financial planner Ken Waltzer, co-founder and managing partner of KCS Wealth Advisory in Los Angeles. “Even if you don’t face a big event like that, the smaller ongoing expenses can really add up.”

Universal Images Group | Getty Images

Roughly 51 million older adults are enrolled in Medicare. Beneficiaries can stick with just Part A (hospital coverage) and Part B (outpatient care) or get their benefits delivered through an Advantage Plan. Part A typically costs nothing, and Part B has a monthly standard premium of $135.50 for 2019.

About one-third of beneficiaries use Advantage Plans, which offer out-of-pocket maximums and often include dental and vision coverage or other benefits. Those plans also typically provide Part D prescription drug coverage. The average premium for an Advantage Plan is $29, according to the Kaiser Family Foundation. Some, however, come with no premium.

The other two-thirds of recipients choose to go with original Medicare (and pair it with a standalone Part D prescription plan).

Supplemental coverage among beneficiaries with basic Medicare

Medigap 29%
Medicaid 22%
Other coverage 1%
No supplemental coverage 19%

In that situation, unless you have some type of employer-sponsored insurance or you get extra coverage from Medicaid, the option for mitigating your out-of-pocket costs is a Medigap policy.

Those supplemental policies, which are sold by private insurance companies, either fully or partially cover cost-sharing aspects of Parts A and B, including deductibles, copays and coinsurance. They also limit what you’ll pay out of pocket each year.

Yet about 19%, or 6.1 million,  who stick with basic Medicare have no extra coverage, according to a 2018 study from the Henry J. Kaiser Family Foundation.

That’s risky, experts say. While Part A is free for most beneficiaries, it comes with a $1,364 deductible per benefit period. And although Part B comes with a low $185 per-year deductible, you typically pay 20% of the remainder for most doctor services — including while you’re a hospital inpatient — as well as outpatient therapy and durable medical equipment such as wheelchairs or walkers.

“That 20% is after your deductible, and there’s no limit to how much you’d pay out of pocket,” said Elizabeth Gavino, founder of Lewin & Gavino in New York and an independent broker and general agent for Medicare plans.

“If you have a heart attack, need multiple surgeries and hospital visits, you could literally end up bankrupt,” she said.

Heart bypass surgery can cost more than $100,000, according to Statista. Heart-valve replacement can run upwards of $170,000. For illustration purposes only: If all those charges were delivered through Part B, your 20% share would be at least $20,000 for the bypass and $34,000 for the valve replacement.

A 65-year-old male will pay anywhere from $126 to $464 monthly for a Medigap policy, according to the American Association for Medicare Supplement Insurance. For 65-year-old women, the range is $118 to $464.

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When you first enroll in Medicare Part B, you get six months to purchase a Medigap policy without an insurance company nosing through your health history and deciding whether to insure you. After that, unless your state allows special exceptions, you have to go through medical underwriting.

While a number of companies offer Medigap insurance, they can only offer policies from a list of about 10 standardized plans. Each is simply assigned a letter: A, B, C, D, F, G, K, L, M and N. Some states also offer a high-deductible version of Plan F.

This standardization means that, say, Plan A at one insurance company is the same as Plan A at another. Be aware, however, not every plan is available in all states. They also do not cover any costs associated with Part D prescription drug coverage.

Everyone should at least consult with a Medicare agent to understand what the results of their choices could be.

Carolyn McClanahan

CFP and founder of Life Planning Partners

The plans differ on what is covered. For instance, Plan F pays your Medicare deductibles while Plan A does not.

Or, some plans cover 100 percent of your deductibles and co-insurance, while others might only pay a portion of those costs. The Centers for Medicare and Medicaid Services has a chart on its website that shows the differences. You also can use the agency’s search tool to find available plans in your ZIP code.

It’s worth noting that beginning Jan. 1, 2020, Medigap plans that are newly sold won’t be allowed to cover the Part B deductible. If you already have a policy that provides that coverage, though, it will continue.

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CFP Carolyn McClanahan said if you can’t afford a Medigap policy, you should consider an Advantage Plan to help gird against endless medical bills. If you can find one with no premium, you’ll at least get protection from its out-of-pocket maximum — even if you have to use in-network doctors and other health facilities to avoid paying more.

“It might limit how you use Medicare, but at least you wouldn’t be on the hook for a potentially exorbitant amount of money,” said McClanahan, founder of Life Planning Partners in Jacksonville, Florida.

She also said that before you make a decision on your coverage, you should check in with a professional.

“Everyone should at least consult with a Medicare agent to understand what the results of their choices could be,” McClanahan said.

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