We can’t afford my spouse’s inpatient rehab treatment. What are our options?
Editor’s Note: Journalist Philip Moeller is here to provide the answers you need on aging and retirement. His weekly column, “Ask Phil,” aims to help older Americans and their families by answering their health care and financial questions. Phil is the author of the new book, “Get What’s Yours for Medicare,” and co-author of “Get What’s Yours: The Revised Secrets to Maxing Out Your Social Security.” Send your questions to Phil.
Ron – Texas: My spouse is 76 and has been disabled for years due to congestive heart failure and other problems. He was recently in the hospital with pneumonia. He is unable to walk and has problems with expressive speech, has been diagnosed with short-term dementia, has had triple bypass surgery and has multiple other problems. He is currently in inpatient rehab for physical, speech and occupational therapy. We are both receiving Social Security and cannot afford extensive inpatient rehab treatment. He is covered by a Medicare Advantage plan. We will be discussing alternatives with his primary physician concerning qualification for being homebound and receiving home-health services. Any thoughts you have would be extremely helpful.
Phil Moeller: I’m so sorry to hear of your spouse’s health problems. I wish you both the best.
In terms of insurance, basic Medicare does not cover so-called custodial care in the home, but does provide up to 35 hours a week for nursing and home-health aides in addition to rehabilitation therapy. This short-term home care must be considered medically necessary by his doctor, and he must be homebound. However, the doctor can prescribe care for multiple 60-day coverage periods.
Medicare requires that such care be provided by a certified home-health agency, and it has online tools to help you find one. The issue, however, is not so much qualifying for Medicare’s home-health benefit as finding an agency to provide the care. Your Medicare Advantage insurer might be able to help here, but as I noted in a recent story, there is no requirement that agencies must take on patients such as your spouse, and finding a care provider can be difficult.
Because your spouse has serious multiple health problems, it’s likely his insurer has a special program to coordinate his health needs. This program may have some additional benefits for home-based care, which generally is less expensive than care in a hospital or skilled nursing facility.
Lastly, if your spouse’s health is failing, you might wish to discuss with his doctor whether he thinks at-home hospice care is appropriate. Medicare provides in-home hospice care and pays for nearly all of its expenses. To qualify for hospice, his doctor has to certify that he expects your spouse to have no more than six months left to live. Many hospice patients live for longer periods, but that’s the approval standard. Of course, I hope your husband’s health has not reached this point, but from your description, it seemed to me that it should be included in the discussion.
Zahida: My father passed away at age 63 and had just started receiving Social Security benefits at age 62. My mother is 57, hasn’t remarried and is unemployed. At what age will she be able to receive a widow’s benefit? Approximately how much will they be, and when she turns 62, will she be able to collect her own benefits plus my dad’s?
Phil Moeller: Your mother’s earliest eligibility date for widow’s benefits is when she turns 60, although benefits taken at that age will be reduced due to early filing.
I can’t say how much they’ll be. It depends on the size of your dad’s benefits.
She will never receive both her widow’s and retirement benefits, but she can receive her widow’s benefit now, let her own retirement benefit grow via delayed retirement credits and then file for it at a later age. If her retirement benefit was greater than her widow’s benefit, she’d received an additional payment equal to the amount by which her retirement benefit exceeded her widow’s benefit.
You should work with your mom to help her develop the best claiming strategy. She can open an online “my Social Security” account which will show her earnings record at different claiming ages. It also will help if she has a record of your dad’s benefits.
If her widow’s benefits are going to be larger than her own retirement benefits, you should consider whether she should wait to claim them until her full retirement age, when they will reach their maximum amount.
If, on the other hand, her retirement benefits will be the larger of the two, then she should file right away for a reduced widow’s benefit and then file for her own retirement benefit when she turns 70.
Lori – Washington: I have just qualified for Social Security Disability Insurance. I’m faced with the decision to either stay with my private health plan (a health maintenance organization) or go on Medicare. My HMO has always delivered excellent care for all of my health concerns, most of which stem from type 1 diabetes, which I have had for nearly 45 years. I just turned 55, and I think I can still afford to pay my health insurance premiums. Can you offer any suggestions to help me make the decision about what to do?
Phil Moeller: You should compare your HMO with the Medicare choices at your disposal.
Because you like your HMO care, I’d first check with your doctors to see what types of Medicare plans they work with. If the answer is “none,” then your choice seems pretty clear!
If they do work with Medicare, I’d suggest you compare available plans in terms of their costs and coverage features. This may take some time, but it can be done. My Medicare book has lots of tips about how to do this.
It’s my understanding that you can stay on your private plan until age 65 without triggering Medicare’s late enrollment penalties. You should confirm this, and please do let me know if you are told that your Medicare enrollment window begins now.
Of course, if you never enrolled in Medicare, these penalties would be moot. But insurance rules and health conditions do change, of course, and so you might want Medicare someday. I’d only note that if that’s the case, you need to be aware of these late-enrollment penalties.
Joseph: I work in the insurance industry, and it’s so important that people know what their getting into before making decisions. I’m trying to find out if employers are allowed to pay for part of their employee’s Medicare costs and premiums?
Phil Moeller: According to a spokesman for the Centers for Medicare & Medicaid Services, it is illegal for an employer to provide an employee with any type of financial inducement that would could be construed as causing the employee to discontinue group employer health insurance in favor of Medicare.
Without such a rule, employers would be motivated to save themselves lots of money by shifting their employees onto Medicare by offering them payments to move.
This rule, by the way, only applies to situations where the employer plan would be the primary payer of covered claims, with Medicare being the secondary payer. In situations where Medicare is primary and the employer plan secondary, employers are permitted to receive subsidies, which can then be used to subsidize Medicare payments. This is common, for example, in employer retiree health plans, with employers providing health reimbursement accounts that include Medicare premiums as one of the permitted use of funds.