Medicare Advantage Plan? Caution! A news post from NAELA states that some MA insurance companies are using computers, not doctors, to tell you how much care you will get. Here’s the note:
Health insurance companies have rejected medical claims for as long as they’ve been around. But a STAT investigation found artificial intelligence is now taking their denials to new heights in Medicare Advantage, the taxpayer-funded alternative to traditional Medicare that covers more than 31 million people. Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying treatment of seriously ill patients who are neither aware of the algorithms nor able to question their calculations. Older people who spent their lives paying into Medicare, and are now facing amputation, fast-spreading cancers, and other devastating diagnoses, are left to either pay for their care themselves or get by without it. If they disagree, they can file an appeal, and spend months trying to recover their costs, even if they don’t recover from their illnesses. <end>
The article refers to the STAT publication, which is an expensive subscription service.
Moral? If you develop medical conditions that may require expensive care, the time may be now to leave a Medicare Advantage plan and return to traditional Medicare with a Medigap policy. It will likely cost more but your doctor, not an insurance company, will determine what treatment you get.
Here’s a common situation. Dad has died Mom has been living in the home with help of the children. She refused to leave and live with her daughter. Then she had a bad fall, broke her hip and she could not return to home so she had to stay in a nursing home. The kids had to apply for Medicaid after her savings ran out. Now oldest daughter spoke to another family at the nursing home and they told her
“Medicaid will get your house after your mother dies.”
Is it true? YES. Medicaid will require sale and payback for what Medicaid paid.
OR: Mom and Dad have been getting Medicaid assistance in home including payment of hospital, doctor and pharmacy bills. They are in their 60’s and not in a nursing home. They heard Medicaid will want payback after they die. The family could lose their home to pay the bills
Is it true? YES. Depending on your state, your Medicaid program may require payback from the “estate” of all recipients over age 55 after they die.
Even now, can we save the home from Medicaid? In many states, “Yes.” In some states “Maybe.”
Caution: This is a very complicated subject because the rules vary depending on when and where you live. Our mission then is to give you hope that not all is lost. The following commentary is thoughts for you to pursue further. You must consult with an experienced local elder law attorney on these questions. Each state is different and each state’s Medicaid program can be changed without notice.
All states: All states must hold off estate recovery while a spouse, minor or disabled child lives in the home and if a sibling co-owner lives in the home. After the condition expires the state may go ahead.
Michigan: I’m in Michigan, so here are some ideas for fellow residents. First Michigan Medicaid estate takes place only through probate. So avoid probate, avoid losing the house. Can Mom sign a deed, or has she given someone “power of attorney” to do it for her? If so, the most common safe method is the “Lady Bird Deed.” Joint deeds signed after entry into the nursing home at this stage are subject potential Medicaid transfer of assets (divestment) penalties (loss of coverage for a long period of time). Trusts are not an option since putting a home in trust causes the home to lose its exempt asset status and will be counted the same as money in the bank.
What if Mom cannot sign a deed and there is no power of attorney? Then probate will be unavoidable. But wait, all may not be lost! In Michigan, Medicaid waits until YOU open an estate, they don’t do it. So, can you wait? Yes. Under current probate procedure if nobody has opened a probate estate within three years of the recipient’s death, then whomever opens an estate afterward does not need to notify any creditor, including the state of Michigan Medicaid. The home could then be sold or transferred to a child and the state of Michigan will not get anything.
Caution again: do check these comments out with a local elder law attorney. Rules do change and may have changed.
Will this hold-off probate work in other states? Perhaps. Check with your local elder law attorney.
Other States: Some states’ recovery programs are not limited to probate. They have “expanded estate recovery” which means Medicaid can pursue any property that the recipient had an interest in. This includes jointly owned property.
Some states have “TEFRA Liens.” That means the Medicaid agency places records a lien at the county/state property office while the recipient is still alive and receiving Medicaid long term care services. The State must release the lien if the recipient is discharged and returns home.
Removal from Nursing Home – Hospice Care: Dissolution of the lien upon leaving the nursing home brings up a “Hail Mary” option. If the home is very valuable, and Medicaid’s claim would be very large, and if family can support her, then perhaps she could return to home or a child’s home on hospice care. Medicare would supply a hospital bed and the hospice benefit could provide other needed equipment and medications. That would remove the TEFRA lien. The home could be transferred to children or sold since Medicaid services are not being used. Then the remaining issue would be Medicaid estate recovery, which may be avoided if there is NO property in her name at death. I’m sure you can see this is a high-stakes situation and I know you would not undertake the Herculean effort without local elder law counsel.
Conclusion and Moral: See a local experienced elder law attorney to explore your options. “It is never too late.”
Elder law concerns the legal issues that confront seniors because they are elders. We might say there are three broad categories of life issues that Elder Law addresses. Our first category is government and private benefits. A good example is Social Security for those age 65 and over. The second category is Elder Law focused estate and personal planning. It includes not only the “death and inheritance” issues but also the personal life-care matters of who will help you when you need help and what will they do. A third category, broader and less well defined, deals with the disabilities that accompany aging
First category, Government and private benefits: Questions relating to Medicare and Medicaid benefits are predominant here. Private benefits can include insurance issues such as long term care policies or pension plan benefits. We can say that IRAs and 401k plans fall in this category and because they involve issues of the federal tax code and IRS rules many Elder Law attorneys team with tax attorneys to get you the best result.
The second category includes what is commonly called “estate planning.” Here we have the usual wills and trusts effective on death to deal with “who gets what?” It also includes personal life-care planning to address aging disabilities, answering questions of who will help the elder, how will they follow the elder’s wishes and how will the elder’s financial resources be used to guarantee the best quality of life. It is a surprise to many estate planners that life-care planning may use a trust, not for after death inheritances, but for life-care planning to make sure the elder has the best quality of life.
The third category includes broad array of matters including such aging related maters as: probate court guardianship-conservatorship; working with professionals such as nurse and social work consults in setting up an in-home assistance program and paying in-home “employees” in accordance with law; dealing with senior apartment and assisted living residence issues that revolve around the resident’s lease-contract; nursing home issues including quality of care and enforcement of resident’s rights guaranteed by law. This list is not all inclusive but a sample of the matters your Elder Law attorney can help you with.
Note that elders who live in assisted living facilities or nursing homes are there because of the disabilities of aging. When they are injured, such as having a fall while being assisted, or ignored, by facility employees they have a “personal injury claim.” Elder Law attorneys know and work with the best personal injury attorneys, who often specialize in helping elders.
When an elder is the victim of a scam it is a matter of criminal law and the county prosecutor’s office often has an office that specializes in this area. If the elder is subject to physical abuse or neglect the state of Michigan adult protective services should be your first call, 855-444-3911. For more Elder Abuse Resources call 800-24-ABUSE (22873). Note that this area of law may require the hiring of an Elder Law attorney to file in probate court for a guardian or conservator of the elder. That is not the purpose of the state of Michigan elder abuse offices.
If an elder has traffic tickets, disputes with neighbors or city hall or other common complaints and you need an attorney, a call to the bar association referral service may be your best bet.
All the best,
Jim
Choosing a new Medicare plan can be an exhausting investigation. I’m sure you’ve read many, many pages in your investigation. So my goal here is not to tell you everything you need to know, but rather a quick read on Key Points to investigate “Medicare Advantage Plans.” The biggest point is do not simply look at dollar cost. Look at Your medical needs. Medicare Advantage plans do have big differences in the details.
Note, we will not cover “extra benefits.” You can decide on your own if a benefit is worthwhile to you.
Key Points
1. Are you healthy and have not seen a doctor or take any medications? You may take the risk of simply choosing a plan that covers the hospital near you.
2. Review your past year’s experience with your current plan.
a. Are you satisfied with your doctors, your pharmacy? Of course if you are not satisfied you will look at other plans. But even if you are satisfied, review your plan for the next year and look for changes that would affect you. They can and do change!
b. If you want to change doctors then determine if the doctor you want is in the plan’s network. Is the doctor accepting new patients?
3. Review Your plans for next year. Are you planning travel? Out of country?
a. If you are traveling in the United States, an HMO may not be suitable since care outside of the HMO providers is typically not be covered.
b. Unless you have an emergency your HMO or PPO plan may not cover medical procedures if where you will be is “out of network.”
c. PPOs can be more expensive than HMO and require more prior authorizations, but can have a much wider provider network and that would be critical if you plan major travel.
d. Out of country travel usually requires additional medical insurance.
4. Are you contemplating any major medical procedures next year? Investigate. Not all plans have the same provisions.
a. Again, is your preferred doctor in the plan network and accepting new patients?
b. Will the procedure requires prior authorization? Are there treatments or procedures you would like to have that will require prior approval?
5. Medications.
a. Check your plan for next year to see if there are changes that affect your prescriptions.
b. If you want to change your pharmacy plan, go into detail about the exact medication, dosage and amount covered by the plan.
And finally note that traditional Medicare does not have the above limitations. But, and a big “But,” you will need a Medigap plan and that will cost you a premium every month. However, if the above Medicare Advantage plan limitations apply then do investigate traditional Medicare plus Medigap plan and you will know you have complete “no surprises” coverage. And finally you will need plus a pharmacy plan that can bring those surprises back into Your plans!
Good Luck and “Happy Trails to You”
Jim
Many healthy seniors choose a low monthly payment for a Medicare Advantage plan. But when a health emergency strikes -say a broken hip that requires post surgery rehab – the co-pays and deductibles can be horrific! But, you can change your plan without waiting for the end of year open enrollment.
A little known provision of Medicare allows for a “Special Circumstances Enrollment Period.” During such a period you can change your Medicare provider. It will be effective the next month – no waiting. Here’s the word straight from Medicare:
What can I do?
When?
Your chance to join, switch, or drop coverage lasts as long as you live in the institution and for 2 full months after the month you leave the institution.
(Above info comes from: https://www.medicare.gov/sign-up-change-plans/joining-a-health-or-drug-plan/special-circumstances-special-enrollment-periods )
That’s right if you are in the hospital or post-hospital nursing home rehab unit and you face enormous copays and deductibles or your MA plan does not include a rehab unit near your home, you can change your Medicare or Medicare Advantage plan and it will be effective the next month! And after you are out of rehab you can go back to your old plan within 60 days of returning home. Note, that a plan may not accept you but shop around: you will have choices!
All the best,
Jim