Life After 50 Expo

Dear Marci,

By

Dear Marci, I have a surgery scheduled soon and will probably need to stay in a skilled nursing facility to recover afterward. Will Medicare cover my stay in the skilled nursing facility? -Megumi (Honolulu, HI)

 Dear Megumi, Skilled nursing facility (SNF) care is post-hospital care provided at a SNF. Skilled nursing care includes services such as administration of medications, tube feedings, and wound care.

Keep in mind that SNFs can be part of nursing homes or hospitals.  Medicare Part A may cover your SNF care if: You were formally admitted as an inpatient to a hospital for at least three consecutive days You enter a Medicare-certified SNF within 30 days of leaving the hospital, and receive care for the same condition that you were treated for during your hospital stay And, you need skilled nursing care seven days per week or skilled therapy services at least five days per week The day you become an inpatient counts toward your three-day inpatient stay to qualify for Medicare-covered SNF care. However, the day you are discharged from the hospital does not count toward your qualifying days. Also remember that time spent receiving emergency room care or under observation status does not count toward the three-day hospital inpatient requirement for SNF coverage. If you meet all the above requirements, Medicare should cover the SNF care you need to improve your condition, maintain your ability to function, or prevent your health from getting worse. Note: Because of the coronavirus public health emergency, Medicare has removed the three-day qualifying hospital stay requirement for beneficiaries who experience dislocation or are otherwise affected by the coronavirus public health emergency.

According to Medicare, this waiver includes but is not limited to beneficiaries who: Need to be transferred to a SNF, for example, due to nursing home evacuations or to make room at local hospitals Need SNF care as a result of the current public health emergency, regardless of whether they were previously in the hospital Speak to your doctor or hospital discharge planner if you need help finding a SNF that meets your needs. Ask them to find Medicare-certified SNFs in your area that will address your medical needs. If you are in a Medicare Advantage Plan, contact your plan to find out which SNFs are in their network. -Marci 

Dear Marci,

By

Dear Marci, I will be eligible for Medicare soon and may need to enroll. What steps should I take to make sure that I have coverage that works for me?  -Thelma (Atlanta, GA)

 Dear Thelma, There are several steps you’ll want to take when you’re new to Medicare: First, know when to enroll in Medicare Part A (hospital insurance) and Part B (medical insurance). If you are already receiving retirement benefits from the Social Security Administration or Railroad Retirement Board at the time you become eligible for Medicare, you will be automatically enrolled in Medicare Parts A and B. There are three times you can enroll in Medicare Parts A and B for the first time.  First, during the Initial Enrollment Period (IEP), which is the three months before, the month of, and the three months after your 65th birthday. The effective date of your Medicare coverage will depend on when you enroll. If you want Medicare Parts A and B to begin the month of your 65th birthday, you should enroll in the first three months of your IEP.

  Second, if you have a Part B Special Enrollment Period (SEP), it lets you delay enrollment in Part B without penalty if you were covered by insurance based on your, your spouse’s, or sometimes a family member’s current work when you first became eligible for Medicare. You can enroll in Medicare without penalty while covered by insurance based on current work, or for up to eight months after you lose your group health coverage or you (or your spouse or family member) stops working, whichever comes first. Medicare coverage generally begins the first of the month after you enroll.  Third, you can enroll during a General Enrollment Period if you did not enroll in Medicare when you first became eligible for it. The GEP takes place January 1 through March 31 each year, with coverage starting July 1. You may have a Part B late enrollment penalty and face gaps in coverage if you sign up during the GEP. Second, consider enrolling in Part D prescription drug coverage. Medicare’s prescription drug benefit (Part D) provides outpatient drug coverage. Part D is provided only through private insurance companies that have contracts with the federal government. If you want to get Part D coverage, you have to choose and enroll in a private Medicare prescription drug plan (PDP) or a Medicare Advantage Plan with drug coverage (MAPD). Typically, you should sign up for Part D when you first become eligible to enroll in Medicare. If you have creditable drug coverage from employer or retiree insurance, you can delay Part D enrollment without penalty and you don’t need to enroll in a drug plan until you lose this coverage. Contact your employer or drug plan to learn if your drug coverage is creditable. Also note that if you qualify for certain Medicare cost assistance programs, you may be automatically enrolled in a Medicare drug plan.
 
Third, decide between getting your coverage through Original Medicare or Medicare Advantage. Unless you choose otherwise, you will have Original Medicare. Instead of Original Medicare, you can decide to get your Medicare benefits from a Medicare Advantage Plan, also called Part C or Medicare private health plan. Remember, you still have Medicare if you enroll in a Medicare Advantage Plan. This means that you must still pay your monthly Part B premium (and your Part A premium, if you have one). Each Medicare Advantage Plan must provide all Part A and Part B services covered by Original Medicare, but they can do so with different rules, costs, and restrictions that can affect how and when you receive care.  If you get your coverage through Original Medicare, you will also have the option to purchase a Medicare supplemental plan, also known as a Medigap. Medigap plans pay secondary to Medicare and cover some or all of the costs of Medicare cost-sharing. You can only enroll in a Medigap plan if you have Original Medicare. 

Dear Marci,

By

Dear Marci, I will turn 65 soon and need to enroll in Medicare. I’ve heard that there are different parts of Medicare. What are those parts? -Aurelio (Cleveland, OH)

 Dear Aurelio, There are four parts of Medicare: Part A, Part B, Part C, and Part D. Part A provides coverage for inpatient hospitalization, skilled nursing facility stays, home health care, and hospice care. Part B provides outpatient coverage, including for physician services, diagnostic tests, durable medical equipment, and outpatient hospital services. Part C is an alternate way to receive your Medicare benefits; provides Part A inpatient/hospital and Part B outpatient/medical coverage and supplemental benefits not covered by Original Medicare (see below for more information). Part D provides prescription drug coverage. Most beneficiaries choose to receive their Parts A and B benefits through Original Medicare, the traditional fee-for-service program offered directly through the federal government. It is sometimes called Traditional Medicare or Fee-for-Service (FFS) Medicare. Under Original Medicare, the government pays directly for the health care services you receive. You can see any doctor and hospital that takes Medicare (and most do) anywhere in the country. In Original Medicare: You go directly to the doctor or hospital when you need care. You do not need to get prior permission/authorization from Medicare or your primary care doctor. You are responsible for a monthly premium for Part B. Some also pay a premium for Part A. You typically owe a coinsurance for each service you receive. There are limits on the amounts that doctors and hospitals can charge for your care. If you want prescription drug coverage with Original Medicare, in most cases you will need to actively choose and join a stand-alone Medicare private drug plan (PDP). Note: There are a number of government programs that help reduce your health care and prescription drug costs if you meet the eligibility requirements. Unless you choose otherwise, you will have Original Medicare when you enroll in Medicare. Instead of Original Medicare, in most areas you have the option of getting your Medicare benefits from a Medicare Advantage Plan, also called Part C or Medicare private health plan. This means that you must still pay your monthly Part B premium (and your Part A premium, if you have one). Medicare Advantage Plans must offer, at minimum, the same benefits as Original Medicare (those covered under Parts A and B) but can do so with different costs and coverage restrictions. You also typically get Part D as part of your Medicare Advantage benefits package (MAPD). Many plans also cover supplemental benefits that are not covered by Original Medicare, like dental care, vision care, and gym memberships. Many different kinds of Medicare Advantage Plans are available. You may pay a monthly premium for this coverage, in addition to your Part B premium.  -Marci 

Dear Marci,

By

Dear Marci, My mother has significant medical needs and has a hard time covering the costs of her care. I want to help her apply for Medicaid, but I think her monthly income might be higher than the income limit in her state. Is it possible that she could still qualify? -Alfred (Omaha, NE

Dear Alfred, If your mother’s income is above the Medicaid income guidelines in her state, her state may offer a spend-down for aged, blind, and disabled individuals who do not meet Medicaid income eligibility requirements. A spend-down would allow her to deduct certain medical expenses from her income so that she can qualify for ABD Medicaid benefits. If she has medical expenses that significantly reduce her usable income, she can use them to qualify for Medicaid coverage. Below is a general guide to the Medicaid spend-down process. Contact your mother’s local Medicaid office to learn if a spend-down program is available in her state, and the rules for applying. Your mother’s spend-down amount will be the difference between her income and the Medicaid eligibility limit, as determined by her state over a given length of time (one to six months). Some states require Medicaid beneficiaries to submit receipts or bills to Medicaid to show their monthly expenses. Other states may let beneficiaries pay a monthly premium directly to Medicaid for the amount that their income is over their state’s Medicaid spend-down level. Spend-down income limits may be lower than the Medicaid income limits for people who do not have a spend-down.  Each period that your mother has enough medical expenses to meet her spend down, she will have Medicaid coverage. If she does not meet her spend-down amount for a certain period of time, she will not have Medicaid coverage for that time. She can still get Medicaid coverage later if she meets her spend-down amount during another period of the year. Medicare will pay first for covered services, and Medicaid will pay second for qualifying costs, such as Medicare cost-sharing. Your mother’s state may require her to qualify and apply for spend-down for multiple periods in order to qualify for Medicaid inpatient hospital coverage. States with spend-down programs may allow people to use the spend-down program to qualify for Medicaid coverage of their nursing facility stays or home- and community-based waiver services. Note: If your mother’s state does not have a spend-down program, it should have more generous Medicaid income guidelines for people who need nursing home care than for those who do not. Your mother will automatically qualify for Extra Help the first month that she meets her Medicaid spend-down amount until the end of the calendar year (even if she does not meet her spend-down amount every period). Trusts—such as Miller Trusts and Supplemental Needs Trusts or Special Needs Trusts—are available in some states to help people become Medicaid-eligible. Trusts allow people with disabilities and income or assets higher than Medicaid eligibility guidelines to place a portion of their income or assets into the trust, where it will not be counted. Rules about how these trusts work vary greatly by state. For more information, contact your mother’s local Medicaid office or an elder law attorney. Some states offer the Medicaid Buy-In program, which allows people who are under age 65 and have a disability to work (as little as one hour per month) and still receive Medicaid benefits. The program is designed to help people with disabilities who would otherwise not be eligible for Medicaid health coverage because their income or assets are too high. If your mother qualifies, she may be able to receive Medicaid by paying a premium to buy in to the program. Financial eligibility guidelines vary by state. Check with your local Medicaid office for eligibility information.  If your mother decides to work and is receiving Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), check with her local Medicaid office to see how much earned income she is allowed to have without losing those benefits. -Marci 

Dear Marci,

By

Dear Marci, 

I have Medicare, and I sometimes find it difficult to afford the costs of my health care. One of my friends suggested that I apply for Medicaid. What is Medicaid, and how does it work with Medicare? 

-Jeanne (Manchester, NH) 

Dear Jeanne, 

Medicaid is a federal and state program that provides health coverage for certain people with limited income and assets. Each state tuns various Medicaid-funded programs for different groups of people, including older adults, people with disabilities, children, pregnant people, and parents and/or caretakers of children. All states have Medicaid programs for people with limited income and assets who need nursing home care, long-term care services, and home health care services. Some states also have programs for individual adults who do not fit any of these categories.  

If you are eligible for both Medicare and Medicaid (dually eligible), you can enroll in both. If you qualify for a Medicaid program, it may help pay for costs and services that Medicare does not cover. Here are a few examples of how Medicaid can work with Medicare: 

  • Medicaid can provide secondary insurance: For services covered by Medicare and Medicaid (such as doctors’ visits, hospital care, home health care, and skilled nursing facility care), Medicare is the primary payer. Medicaid is the payer of last resort, meaning it always pays last. When you visit a provider or facility that takes both forms of insurance, Medicare will pay first and Medicaid may cover your Medicare cost-sharing, including coinsurance charges and copays.  
  • Medicaid can provide premium assistance: In many cases, if you have Medicare and Medicaid, you will automatically be enrolled in a Medicare Savings Program (MSP). In other cases, you can apply for an MSP even if you are not automatically enrolled. MSPs pay your Medicare Part B premium and may offer additional assistance. 
  • Medicaid can provide additional cost-sharing assistance: Depending on your income, you may also qualify for the Qualified Medicare Beneficiary (QMB) MSP. If you are enrolled in QMB, you do not pay Medicare cost-sharing, which includes deductibles, coinsurances, and copays, when you see a provider who accepts Medicare.  
  • If you are eligible for Medicaid, you are eligible for prescription drug assistance: Dually eligible individuals are automatically enrolled in the Extra Help program to help with their prescription drug costs. 
  • Medicaid can offer care coordination: Some states require certain Medicaid beneficiaries to enroll in Medicaid private health plans, also known as Medicaid Managed Care (MMC) plans. These plans may offer optional enrollment into a Medicare Advantage Plan designed to better coordinate Medicare and Medicaid benefits. Note: You cannot be required to enroll in a Medicare Advantage Plan. 

Make sure to call 1-800-MEDICARE or contact your local Medicaid office to learn more about Medicare and Medicaid costs and coverage, especially if you are dually eligible. 

-Marci