Mission: To educate and improve the experience of aging for mature adults and their caregivers.

Understanding Medicare and Medicaid

Understand Medicare and Medicaid and How It Helps Your Parents

Website:  http://www.medicare.gov

Medicare Basics

Sign Up for Medicare:

Ten thousand Boomers are turning 65 every day and many of them are getting signed up for Medicare.  Medicare is a federal health insurance program for individuals over 65.  Once a person signs up for Social Security, they are automatically enrolled in Medicare.  However, if they have not yet begun to collect Social Security, then they will need to speak to a Social Security representative up to 3 months before their 65th birthday.  Even if an individual decides to wait or is covered under a spouses medical plan at work, it is important to talk to a representative so that they know what the rules are.  Otherwise, they may end up paying higher rates from the point they enroll.

Medicare A, B, C, D, Medigap:

There are several parts to the Medicare coverage.  Part A covers hospital stays and hospice services; Part B covers physician services, lab costs, and other therapy.  Medicare C covers managed care plans and Medicare D covers drug prescriptions.  Medigap policies are insurance plans to cover the out of pocket expenses that Medicare does not cover such as out-of-pocket costs for Medicare coinsurance and deductibles or services not covered by Medicare.  It will also pay if costs exceed the Medigap premium.

What is covered?

Here is a snapshot of what Medicare does and does not cover.  It does pay for emergency care, a second opinion by a Medicare-approved doctor, lab costs and outpatient mental health.  Some diabetes supplies and services are also paid for by Medicare.  It does not pay for in-home care, health care while traveling outside the US, insulin and syringes used by diabetic patients.

Medically Necessary:

A very important concept to understand when dealing with insurance in general is the term “medically necessary”.  “Medically Necessary” is a term that is used to determine if care is warranted.  Certain procedures are deemed to be medically necessary in order to begin healing.  However, other procedures while they may improve condition or speed recovery are not determined to be medically necessary to the healing process.  If you dispute the determination, you can appeal the decision and your doctor and a second opinion doctor will need to make a case for the procedure being recommended.  There are time limits and guidelines for making these appeals.  Be sure to adhere to them.

Open Enrollment:

What is Open Enrollment?  It is the period when you can re-evaluate your choices in coverage for Medicare Part A, B, C, and D for the upcoming year.  Use the evaluator provided by Medicare at  www.benefitscheckup.org.  Consider costs, quality of care, and your needs in mind when evaluating options.

If You Need To Speak for Your Parent:

As a caregiver speaking on behalf of a parent, you will need to file a Form CMS 1696-U4 which allows access about benefits from both the SSA and Medicare.  Your parents will be asked to join you on a call to give their consent for you being able to access their information.  To get a form, call 1-800-633-4227 or download it from www.medicare.gov.  To reach the Social Security Administration, go to www.ssa.gov or 800-772-1213.

Maintain a Personal Health Record

A Personal Health Record is critical to a caregiver when speaking on behalf of their loved one.  For a form offered by Medicare, go to www.medicare.gov.  The Blueprint for Care workbook offered on the Caring for Parents Together website offers the personal health history, medication list templates, emergency contact forms, legal documents checklist, end of life wishes template, a safety checklist and much more.  Go to www.caringforparentstogether.com to find out more.

Estimate Your Social Security

Go to www.socialsecurity.gov/estimator to find out what your benefits will be when you begin to collect them.  You may begin to collect at age 62, at age 65 or at age 70.  The longer you wait, the higher the benefit you will receive.

Medicare Fraud

Medicare fraud happens every day.  Have your loved one safeguard their card number and never give it out over the phone.  If a salesperson comes to the door uninvited, do not let them in.  Never sign anything without first having read it.  Do not be pressured!

Making changes to Medicare is a very serious matter.  Make sure it is right for you!  Call the local SHIP Program at 1-800-390-3330 to discuss your changes and verify that you are making a good move.  Do your investigation about the options before talking to any sales representative.

If you suspect billing fraud on behalf of a provider, call the fraud hotline of the Department of Health and Human Services at 800-447-8477.  Educate yourself about health care costs and procedures ahead of time so you will know what to expect.

When your loved one dies, report that the number is no longer being used to the Social Security office to prevent abuse and fraud.

Medicaid Basics

Medicaid is a joint federal-state health program established by Congress to provide medical coverage to people whose assets are meager and qualify based on certain criteria.  Check with an Elder Estate Attorney in your state to determine what the criteria is in your area.

Qualifying criteria include:

  • Person is 65+
  • Disability or blindness
  • Needing nursing home care
  • Countable resources of no more than $999.99 if single and $1999.99 if married
  • Income of no more than $623 is single and $924 if married

Countable resources include savings, checking accounts, CDs, IRA’s, Keogh’s, cash surrender value of life insurance, non-homestead real estate; fair market value of a second, third or more automobiles; boats and motors.

Exempt resources include:  the person’s home, one car, wedding and engagement rings, burial plots for each spouse, household and personal belongings, and Cash Surrender Value of less than $1500.

Division of Assets:  If assets are dwindling and one of the spouses needs to go into a nursing home, rather than impoverish both spouses, Medicaid will do a Division of Assets.  This means that a Monthly Maintenance Needs Allowance of at least $2,000 is determined.  If there is not enough for $2,000, then income is taken from the nursing home spouse’s income to make up for the deficit.  Medicaid makes up the difference for the spouse in the nursing home.

Penalties:  If it is determined that the spouse gave large gifts to charities or children during the 60 months preceding getting onto Medicaid, there will be a penalty period.  That will mean that the person will not be able to receive Medicaid assistance until the penalty period is up.

Applying for Medicaid  If an older adult’s assets are dwindling and they are not able to replenish them, do not wait until the last minute to get them signed up for Medicaid.  Get an attorney involved because they will push it through faster.  It can be a lengthy process.

Go to www.Medicaid.gov for more information.

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