I keep falling. Will Medicare cover a home health aide?

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Sandy Wright gets some help from her Certified Nursing Assistant Jessica Haynes at her home in Peoria, Illinois, November 25, 2013. Wright has Neuromyelitis Optica and has a Certified Nursing Assistant come to help her around the house. Now, patients like Wright are at the forefront of an experiment, under way in Peoria, Illinois, and hundreds of other U.S. cities, that could transform the way doctors, nurses and hospitals deliver care to patients. Amid the barrage of criticism over the rollout of Obamacare, groups known as Accountable Care Organizations (ACOs) are quietly going about the business of testing the potential for healthcare reform. The efforts, born of President Barack Obama's Affordable Care Act, are part of the biggest experiment yet to fix the costly and error-plagued U.S. healthcare system. The new models of care, which encourage providers to form networks to coordinate care and cut costs, involve close monitoring of the sickest patients to address budding health problems before they cause a costly trip to the emergency room or an extended hospital stay. Photo by Jim Young/Reuters

Aging and retirement expert Phil Moeller answers your questions on Medicare and Social Security. Photo by Jim Young/Reuters

Editor’s Note: Journalist Philip Moeller, who writes widely on aging and retirement, is here to provide the answers you need in “Ask Phil.” Send your questions to Phil.


Alanna: My mother is beginning to have terrible knee pain. She fell twice in the house already, and she cannot stand on her own for even 10 seconds. How can I get a home health aide for her, and if I do, does that mean she would lose her Supplemental Security Income?

David – Tex.: Sooner or later, I will fall again. Prevention includes a shower stall for people like me. Will Medicare help cover the expense of a replacement shower? I am 70.

Medicare usually only covers things that are deemed medically necessary by your doctor or another health care professional.

Phil Moeller: Alanna and David raise an enormous issue about aging and, in terms of Medicare, the often fine or even invisible line between the normal rigors of getting older and a degree of infirmity that requires and can qualify for professional care covered by Medicare.

The key phase in this discussion is “medical necessity.” Medicare usually only covers things that are deemed medically necessary by your doctor or another health care professional. This means your doctor must request equipment or care as necessary to your health.

In Alanna’s case, I should first say that I know of no reason why Medicare coverage of a home health aide would end her mother’s eligibility to continue receiving Supplemental Security Income payments. Those payments are tied to income, and having insurance cover an expense will not affect her mother’s income.

The standards for qualifying for a home health aide are rigorous. According to the Medicare Rights Center, there are four conditions that must be met to gain insurance coverage here.

1. You must qualify as being homebound, meaning you need the help of another person or special equipment (wheelchair, walker, crutches, etc.) to leave your home, it is hard to do so, and, your doctor thinks leaving your home might be bad for your health.

2. You need skilled as opposed to custodial care. This care requirement may not be constant but intermittent. If it were constant, you’d need to leave your home and get covered care in a nursing home or other facility. This skilled care can include various types of physical, speech, and occupational therapy.

3. Your doctor signs a home health certification saying you need home care because you’re homebound and require intermittent care. He or she also must attest that a plan of care has been created for you, and the doctor is reviewing it. This certification usually includes the doctor’s confirmation that he or she has seen you in person.

4. You must receive your home health care from a Medicare-certified home health agency.

In David’s case, his doctor would have to certify that a senior-friendly shower stall is medically necessary. This is much more of an uphill climb than Alanna’s mother faces. Shower and other senior “friendly” bathroom and home modifications may be useful and even lead to reduced falls and injuries. But Medicare usually does not consider such improvements to be medically necessary. So I’m afraid that David would have to pay for such improvements out of his own pocket.

READ MORE: Medicare won’t cover a procedure I need. Can I get private insurance?


Ellen – Pa.: My husband plans on working beyond 65. As part of a buyout option he took, he has a lifetime medical plan with a former company. He said the company said he must apply for Medicare at 65, so his benefits with this former employer can become secondary. In this case, do we take this as a “no choice option” with this buyout plan and that what this company is telling him is correct? Would this mean we have to continue to pay for the company’s benefits plus the added fee for Medicare benefits?

Most employer retirement health plans are designed so that Medicare becomes the primary payer when a covered person turns 65.

Phil Moeller: Yes, it does. Most employer retirement health plans are designed so that Medicare becomes the primary payer when a covered person turns 65. At the time, the employer plan becomes the secondary payer. While it might seem unfair that you have to pay for both the employer plan and Medicare, the costs to you for the employer plan are based on its assumption that you will get Medicare. This lowers the costs to the employer plan, and these lower costs should be reflected in the design of its premiums. Also, when you say that Medicare will become the primary payer, does this include drug coverage as well, or will your employer plan remain primary when it comes to Part D drug coverage? Once you find this out from the retiree plan, you can decide if it would be cheaper for you to leave the employer plan and rely totally on Medicare. In most cases, it’s still better to stay on the employer retiree plan. Its role as a secondary payer most likely will limit your out-of-pocket expenses. In Medicare, you would need either a Medigap or Medicare Advantage plan to achieve this protection. And you would thus need to include these costs along with your other Medicare coverage to get an accurate comparison of a Medicare-only coverage plan versus your Medicare-retiree plan.


Jamie – Ind.: I live in Indiana, but am traveling to Florida for a couple weeks. I’ll have a prescription that needs to be refilled while I’m gone. I believe I have Medicare Parts A and B plus a Part D prescription plan. Will I be able to get it filled with a pharmacy in Florida?

READ MORE: Am I still covered by Medicare when I travel out of state?

Phil Moeller: If you have a stand-alone Part D plan and Original Medicare, you should be fine. But as with nearly everything about Medicare, it’s best to check this out with your plan before you travel and not assume you’ll be able to fill the prescription. In particular, if your Part D plan uses a proprietary pharmacy network – and most do – you will want to make sure you won’t be hit with price penalties when you fill this prescription in Florida.


Dawn – Germany: My husband is in an 18-month to 3-year job as a civilian contractor with the U.S. Army in Germany. He turned 65 in June while in Europe and we are struggling with the question as to whether he needs to enroll in Medicare. He has an insurance plan with the company he works with, and we know that Medicare does not provide coverage outside of the U.S. So is he required to enroll now in Part A? Or does he wait until he moves back to the U.S.?

Under U.S. law, any private employer with 20 or more employees must continue offering health insurance to active employees when they turn 65 and cannot require them to take Medicare.

Phil Moeller: He is not required to enroll in Medicare. Under U.S. law, any private employer with 20 or more employees must continue offering health insurance to active employees when they turn 65 and cannot require them to take Medicare. He can, however, sign up for Part A if he wishes. And if he takes Social Security, Part A is mandatory. It covers hospitalization, and there is no premium for Part A for anyone who qualifies for Social Security benefits. Part A can be a helpful secondary payer to his private insurance. However, as past Ask Phil columns have explained, having Part A invalidates a person’s participation in a health savings account. If he has one of those, he probably will not want to get Part A.


Tina – Ill.: My husband is 54 and draws Social Security Disability Income due to severe health issues. When he was granted Social Security Disability Income, he was automatically signed up for Medicare Parts A, B and D. I am still employed and carry insurance through my employer. We were not planning on taking Parts B or D until he turned 65 due to the cost. I am working part time so my income is not great after benefits, but that is another story. He was automatically signed up by an insurance plan through Medicare Part D for low-income people. Is there any way we can force Medicare to drop the Part B and Part D until he is 65? This is really messing up my doctor’s office. It is insisting that Aetna is primary and Aetna (my insurance) is insisting Medicare is primary. We are stuck in the middle of this. Personally, I would rather not pay for the Parts B and D right now. I understand that Medicare Part A is free since he is on disability. Can you help me to understand why we have to pay for Part B right now when he does not need it?

Phil Moeller: First, make sure with your employer’s insurance benefit office that your plan will cover him. If it will, he cannot be forced to take Medicare at this time. Saying this is easy. Getting back your premiums may not be so easy. My advice is to pull together all of your insurance information and then get in touch with a Medicare counselor in Illinois who works with the State Health Insurance Assistance Program. This free service should be able to help you stop any unneeded Medicare premiums and get back past premiums that you did not need. I am hoping here that your husband never filed any claims with Medicare. If he did, getting back those earlier premium payments would be much, much harder. Good luck, and please let me know how things turn out.


Dave – Philippines: I am a nearly 68-year-old expat receiving Social Security benefit payments. I have just been informed that the Social Security Administration will begin deducting Medicare premiums from my payments. I never filed any agreement — digital, verbal or written — to be enrolled in Medicare. However, I do see from my online Social Security Administration account that I am, in fact, enrolled. It appears this is some sort of automatic enrollment (grrrrr). Since I am a permanent resident of the Philippines, where Medicare is of no use, and because I have no intention to visit the U.S. for more than two or three weeks at a time, I’d like to know how I can opt out of Medicare entirely. Thanks for all you do.

Phil Moeller: Dave, I am “grrrrr-ing” right along with you! You should not have to pay these premiums. This process is overseen by the Social Security Administration, which handles a lot of Medicare administrative tasks. My first stop would be the U.S. embassy in Mania. Here’s the contact information provided on the SSA website:

Philippines American Embassy

1201 Roxas Boulevard

Ermita, Manila 0930

Philippines

Phone: 632-301-2000

Fax: 632-708-9714 or 632-708-9723

Email: FBU.Manila@ssa.gov

READ MORE: I didn’t want Medicare Part B. Why did Social Security enroll me in it?

This office should be able to help you opt out and recover any improper deductions from your Social Security payments. Good luck, and please let me know how things turn out.


Antonio – N.M.: I will turn 65 this week, am self-employed and will probably not apply for Social Security until age 70. My wife is eight years younger, works for the federal government and carries me on her health plan. Do I have to sign up for Medicare? What are the pros and cons of doing this? Will these issues be covered in your upcoming book? Do I have enough time to wait until then to do something?

Phil Moeller: Antonio, you don’t have to sign up for Medicare as long as your wife is actively employed and you are covered by her health plan. However, you do have the right to do so when you turn 65, and you will not face a late-enrollment penalty if you do so any time during the three months following your birthday month. The only reason to sign up for Medicare is if there was a significant gap in your coverage under your wife’s plan. But if she is covered by a Federal Health Benefits Program insurance plan, there really shouldn’t be such a gap, and you would get very little if any extra protection for your new Medicare premiums. Before making a decision, talk to your wife’s benefits office, and go over these details yourself.

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