Editor’s Note: Journalist Philip Moeller, who writes widely on health and retirement, is here to provide the Medicare answers you need in “Ask Phil, the Medicare Maven.” Send your questions to Phil.
Your Medicare Questions
Medicare rules and private insurance plans can affect people differently depending on where they live. To make sure the answers here are as accurate as possible, Phil is working with the State Health Insurance Assistance Program (SHIP) and the Medicare Rights Center (MRC).
Karen – W.Va.: My Mom is 88, and my Dad turns 90 this year. They have been relatively healthy until this past year when my Dad began to have small strokes and my Mom fell and broke her hip. She is now also struggling with cerebral amyloid angiopathy, which is causing many symptoms similar to a stroke. Both are disoriented, having severe difficulty with their long and short term memories and some trouble also communicating their thoughts. Neither of them is able to care for each other or themselves or are able to be left alone. My sister, who lives not far from them, has been looking after them almost 24/7 for the last seven months. I live at a distance, have many responsibilities in my life and can only come briefly from time to time. Our situation is not sustainable. In-home care is needed if they are going to remain in their home. Up until now, they have been living independently and would like to stay in their apartment, which they own. My sister says she has explored home care for them, but Medicare has told her they will only pay for skilled care, that is, nurses, rehab etc., which they have both used and Medicare did cover it. I read your qualifications in the PBS piece and my parents certainly qualify in the four categories you name, but my sister is hitting road blocks with Medicare who say they do not cover simple home care under any conditions. Am I understanding what you are saying correctly — do they have some home care in their Medicare coverage? If so how do we get around this roadblock? Who should we be talking to? Thanks so much for any help you can offer. We are quite desperate at this point.
Phil Moeller: This is one of the most significant real-life issues that growing numbers of older Americans and their grown children face. Millions of families will be in Karen’s situation. And we do not have the answers for them. Very few families can afford private long-term care insurance. Medicare certainly does not cover long-term custodial care in nursing homes or other institutional settings. Medicaid is the default provider of long-term care in this country. But older patients need to spend down nearly all of their assets to qualify for Medicaid, and the process of doing do is not only daunting in terms of paperwork, but often demeaning and embarrassing to proud Americans who have worked all their lives. They might be forgiven for feeling they deserve better than to be effectively forced into welfare to become wards of the state and placed in homes that, with all due respect, can easily become warehouses for the elderly poor.
Medicare does cover skilled nursing care, which can be delivered in a home setting. But its coverage was never designed to be a long-term solution. For example, skilled care in a nursing facility gets very expensive after the first 20 days, with a co-insurance cost exceeding $150 a day for days 21 to 100. After that, patients must pay ALL expenses, which would be akin to simply moving into an expensive assisted-living facility.
Skilled care at home can be cheaper for everyone, but again, is not something that Medicare designed as an ongoing, long-term benefit. In Medicare’s online description of its in-home care services, this seems to me to be the key issue that Karen’s parents face: “You’re not eligible for the home health benefit if you need more than part-time or ‘intermittent’ skilled nursing care.” It defines intermittent care being required less than seven days a week or less than eight hours a day. I do agree with Karen and her sister that, with the help of her parents’ doctors, they should be able to make a case for Medicare insuring her parents’ receipt of skilled in-home care, but only as a stop-gap approach. She should get in touch with a local affiliate of the National Association of Area Agencies on Aging, a consortium of non-profits around the country. Ask for a list of home health agencies willing to provide Medicare-covered services. These agencies should know the ropes of intermittent care and should be able to tell you the types and duration of care that will comply with Medicare’s rules.
However, Karen’s parents clearly are in decline. She needs to look for a longer-term solution even if in-home skilled care is approved. Whatever the definition of intermittent may be, her parents will need more than this, and perhaps they will need it soon.
Jane – Calif.: I am a retired federal employee. I retired at age 60 in 2010. I will be turning 65 in October 2015. I am eligible for Medicare as I paid into that. I am now covered by good medical insurance as part of my retirement package. I have two daughters who are also covered by my medical insurance, so I plan to remain in the insurance program I have, possibly for eight more years since my younger daughter is just 18. My question is: I plan to enroll in Medicare Part A, but do I need part B? It seems redundant. And how does Medicare look at my medical insurance since it isn’t due to my current employment, but my former employment?
Phil Moeller: Jane mentions being currently employed but says nothing about whether she could get health coverage from this job and how this would compare with her retiree coverage. Perhaps she already has done this comparison and concluded it’s best for her to stick with the retiree health coverage from her former employer, which includes coverage of her two daughters. Whether Jane needs Part B for herself is something she should determine by finding out more details of her retiree health plan. Retiree health plans generally require retirees to get Medicare. This is because the plans are designed to work with Medicare so that Medicare becomes the primary payer of covered insurance claims, and the retiree plan becomes the secondary payer. If the person has a claim, their secondary often pays most or even all of what Medicare does not pay. But for this to work, the person needs to have Parts A and B. Some retiree plans also have components that support Medicare Advantage plans and Part D prescription drug coverage. These are details Jane’s former employer should be able to brief her about.
As a federal retiree, Jane also may have access to the only retiree health plan that the Medicare Rights Center (MRC) says may not require her to get Part B. The Federal Employee Health Benefits Program (FEHBP) has a rich menu of possible retiree benefits. Sorry for all the initials but writing out Federal Employee Health Benefits Program hurts my wrists, and perhaps your eyes as well. Anyhow, Jane does not identify her retirement plan, but if it’s in the FEHBP family, she should look into it. Here’s what the MRC has to say:
• If you are enrolled in a health maintenance organization (HMO) under FEHBP, you may find that the HMO provides such comprehensive coverage that you do not need to enroll in Part B. You should evaluate your benefits before making a decision not to take Part B. Be aware however, that in an HMO, you may be limited in which doctors, hospitals and pharmacies you will be covered to go see. You will generally pay more to see out-of-network doctors. Having Part B through original Medicare could increase your access to providers; most doctors and hospitals in the country take original Medicare.
• If you are enrolled in a fee-for-service plan under FEHBP, you may find it better to take Medicare because your plan waives most Medicare deductibles, coinsurance and copayments (except for prescription drugs) for people who have Part B. As a result, FEHBP fee-for-service plan enrollees with both Parts A and B find that they have little or no out-of-pocket expenses.
Lastly, Jane should be aware that while it might be possible for her to do without Part B for now, she might face stiff penalties later should she decides she needs it. Her monthly Part B premium could be hit with a late enrollment penalty that equals 10 per cent of the premium for each year she is late in enrolling. And it would last for the rest of her life. Ouch!
Barbara: My sister had a massive stroke about a year ago and is in a nursing home. Her Medicare ran out a few months ago. Does her coverage renew every year or is it a one-time thing?
Phil Moeller: I’m guessing here that Barbara does not mean her sister’s Medicare policy actually expired, but that Medicare stopped covering expenses for her stay in a skilled nursing facility (SNF). I also don’t know what “flavor” of Medicare her sister has. Basic Medicare only covers 20 days of skilled nursing facility care and then tags patients with a $157.50 daily coinsurance fee for days 21 to 100. After that, all costs must be paid by the patient. Some Medigap policies help with the coinsurance payment. Medicare Advantage plans may improve on basic Medicare but she’d need to check with her plan insurer. Once her sister has gone 60 days with no Medicare services, her skilled nursing facility “spell of illness” would reset, according to SHIP counselors who help answer Ask Phil questions. Then she could apply again for covered skilled nursing facility care. If Barbara’s sister has limited financial resources, she might qualify for Medicare Savings Programs to help her with Medicare costs.
Susan – N.Y.: I am currently getting physical therapy. But I am planning to have back surgery in August. If I do my post-operative recovery in the hospital, is there any limit to how much physical therapy I can have (that is, because I’ve already used some of my allotted annual amount in the out-patient physical therapy just to keep me ambulatory enough before the back surgery)?
Phil Moeller: I have always wanted to be able to say that Medicare is a pain in the back. Now, all I need is for someone to send me a question about problems with their derrière! There is a $1,940 cap on physical therapy on charges that Medicare will cover, but there may be exceptions should Susan’s doctor and physical therapist request additional therapy. Remember that basic Medicare only pays 80 percent of covered charges.