Elder Law now encompasses a new area of counseling and representation and that is in Medicare advocacy. This is a change. It’s not that Medicare recipients never benefited from counseling now and then. There have always been benefits that were little known or understood, such as the “homebound” benefit or the extent of the Durable Medical Equipment benefit. The fact is Medicare has changed – it’s not what it used to be.
Perhaps the changes stem from efforts to reduce costs for the program. Whatever the motive, some beneficiaries have received less benefits at more expense. These results are typically the result of the elder being in a Medicare plan that is not suited to their needs. With the new Medicare, seniors should check their insurance needs against the Medicare plan they have and see if adjustments should be made. That often means changing plans during open enrollment. That can be a very prudent undertaking and sometimes an elder law attorney can make the undertaking very worthwhile. Some clients have saved over a thousand dollars a year by a Medicare plan consultation. There are three areas where the Medicare beneficiary can benefit from an informed counselor and advocate:
It is a rule of thumb in the elder law community that Medicare Advantage plans work best for the healthy senior. Here we consider benefits such as annual screenings and consultations on matters such as diet and classes for exercise with a goal being a healthier lifestyle. These programs reward proactive steps and penalize care for those who are chronically ill.
Elders with chronic conditions will often find that they are paying significant monthly medical bills in the form of doctor office visits and high deductibles. The chronically ill elder will often benefit from switching from a Medicare Advantage plan to traditional Medicare with one of the standard Medigap plans.
An elder who is taking many medications, some of which can be very expensive, can often save hundreds of dollars a year by aligning their Medicare Prescription plan with the exact medications they are taking. This requires active management since plans can change their “formularies” every year. The variables in Plan D are 1) the monthly premium; 2) the initial deductible; 3) the prescription co-pay; 4) the formulary of the drugs covered, including whether name brand or generics are on the list, and the quantity limits. Most elders can find a plan that has all of their expensive medications in the formulary. The “rule of the road” is: When you have a complete list of all medications, including dosages, you can then shop for the plan that best meets your needs and you can often save hundreds of dollars a year.
There are currently two areas of active advocacy: 1) Hospital “Observation Status” and the end of the skilled care “Improvement Standard.”
Observation status is an unresolved problem. It refers to the situation where a person is in the hospital for days and then finds out they were never “admitted” for Medicare purposes but rather were in under “observation status” That means Medicare A does not cover the bill and if the patient proceeds from hospital to a skilled care nursing facility, the Medicare 100 day skilled care benefit will not be triggered. That means the patient is stuck with a shockingly large bill.
Senior organizations such as AARP and Medicare advocacy organizations such as the Center for Medicare Advocacy are working with the CMS to clarify and limit the observation status rules. We hope for a clarification later this year.
In the mean time patient advocacy requires on the spot checking with the hospital to see if there has been a formal admission or not and whether the subsequent billing codes fall under in-patient or out-patient care. Some advocates have found that the hospital billing department used the wrong codes, which did not accurately reflect the care provided and resulted in “observation status.”
There is much better news in this area. In January 2013 the federal court ruled in a nationwide class action lawsuit that Medicare could not impose an improvement standard limitation on skilled care. CMS only released official guidance in December 2013 and the word is not yet out “on the street.” Many providers still believe that a patient must improve to receive skilled rehab therapy. Not true.
The Medicare benefit should be delivered even if the patient only maintains function with therapy. The good news here is that the benefit not only applies to skilled care facilities but also therapy in-home. That means no artificial “six week” limitation for therapy in home. As long as benefit can be clinically documented the therapy can continue indefinitely.
This post has only flown over the top of Medicare advocacy. We’ll need posts later to dig into each area in more depth. Till then,
All the best,
Jim