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Jan 31
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Does Medicare Cover Therapy Services?

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Medicare’s Coverage Of Therapy Services Again Is In Center Of Court Dispute

By Susan Jaffe

Four years after Medicare officials agreed in a landmark court settlement that seniors cannot be denied coverage for physical therapy and other skilled care simply because their condition is not improving, patients are still being turned away.

So federal officials and Medicare advocates have renewed their court battle, acknowledging that they cannot agree on a way to fix the problem. Earlier this month, each submitted ideas to the judge, who will decide — possibly within the next few months — what measures should be taken.

Several organizations report that the government’s initial education campaign following the settlement has failed. Many seniors have only been able to get coverage once their condition worsened. But once it improved, treatment would stop — until they got worse and were eligible again for coverage.

Every year thousands of Medicare patients receive physical therapy and other treatment to recover from a fall or medical procedure, as well as to help cope with disabilities or chronic conditions including multiple sclerosis, Alzheimer’s or Parkinson’s diseases, stroke, and spinal cord or brain injuries.  Although it removes the necessity to show an improving health condition, the settlement does not affect other criteria and limitations on Medicare coverage.

“We still regularly get calls from people who are told they are being denied coverage,” said Peter Schmidt at the National Parkinson Foundation, based in Miami. Denials sometimes occur because physical therapy providers use a billing code that still requires the patient to show improvement. Although Parkinson’s is a degenerative brain disease, Schmidt said physical therapy and exercise can help slow its progress.

The agreement, approved in 2013, settled a class action lawsuit against the Centers for Medicare & Medicaid Services filed by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of five Medicare beneficiaries, including the late Glenda Jimmo, and  six nationwide patient organizations. Coverage, the Jimmo settlement said, does not depend on the “potential for improvement from the therapy but rather on the beneficiary’s need for skilled care.”

In August, U.S. District Court Chief Judge Christina Reiss in Vermont ordered the government to work with the beneficiaries’ attorneys to strengthen its education campaign about the policy aimed at bill-processing contractors, claims reviewers, providers, appeals judges, people who staff the 800-MEDICARE help line and others. (Beneficiaries, however, were not included.) After working during the fall, both sides acknowledged this month they could not reach a compromise on the best way to make revisions to the education campaign.

There was a long-standing kind of mythical policy that Medicare contractors put into place that said Medicare only pays for services if the patient could progress,” said Roshunda Drummond-Dye, director of regulatory affairs for the American Physical Therapy Association. “It takes extensive effort to erase that.”

Medicare’s proposals include educational efforts such as a special webpage with “frequently asked questions” spelling out the proper procedures for handling claims. The government would also issue a clear statement confirming that Medicare covers physical, speech and occupational therapy along with skilled care at home, and in other settings, even if the patient has “reached a plateau” — a term seniors still hear — and is not improving.

Attorneys for the seniors want to monitor how Medicare officials implement these new measures and have offered to write the policy statement disavowing what’s known as the “improvement standard.” They also want the government to repeat its 2013 conference call with providers, contractors and others involved in the process in order to correct mistakes, according to papers filed with the court Jan. 13.

“The major problem for us is that they do not want the plaintiff’s counsel to have any say or involvement in what they do,” said Gill DeFord, litigation director at the Center for Medicare Advocacy in Connecticut. “We think that’s exactly the reason the educational campaign was so riddled with inaccuracies in the first place.”

But in its filing, the government said, “The Plaintiffs’ plan seeks to address perceived deficiencies that were specifically not guaranteed under the [settlement] Agreement.” It added accepting the advocates’ plan “would also grant their counsel undue control in developing CMS educational materials and an outsize role in CMS’ corrective action efforts.”

The settlement affects care provided by a trained professional in a patient’s home, nursing home or the provider’s private office that is medically necessary to maintain the patient’s condition and prevent deterioration.

A Medicare spokesman declined to comment under agency protocol because the case is still pending.

KHN’s coverage of aging and long-term care issues is supported by The SCAN Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Oct 19
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2017 Social Security Benefits Increase

By Uncategorized

Social Security Cost of Living Adjustment Announced

retirement benefits

retirement benefits

The annual cost-of-living adjustment (COLA) usually means an increase in the benefit amount people receive each month. By law, the monthly Social Security and Supplemental Security Income (SSI) federal benefit rate increases when there is a rise in the cost of living.

 

The government measures changes in the cost of living through the Department of Labor’s Consumer Price Index (CPI-W). The CPI-W rose this year. When inflation increases, your cost of living also goes up. Prices for goods and services, on average, are a little more expensive. Since the CPI-W did rise, the law increases benefits to help offset inflation.

As a result, monthly Social Security and SSI benefits for over 65 million Americans will increase 0.3 percent in 2017.

Social Security Wage Base Increases to $127,200 for 2017

Other changes that would normally take effect based on changes in the national average wage index will begin in January 2017. For example, the maximum amount of earnings subject to the Social Security payroll tax will increase to $127,200.

The Federal Insurance Contributions Act (FICA) imposes two taxes on employers, employees, and self-employed workers-one for Old Age, Survivors and Disability Insurance (OASDI; commonly known as the Social Security tax), and the other for Hospital Insurance (HI; commonly known as the Medicare tax).

For 2017, the FICA tax rate for employers is 7.65%-6.2% for OASDI and 1.45% for HI.

For 2017, an employee will pay:

  • (a)  2% Social Security tax on the first $127,200 of wages (maximum tax is $7,886.40 [6.2% of $127,200]), plus
  • (b)  45% Medicare tax on the first $200,000 of wages ($250,000 for joint returns; $125,000 for married taxpayers filing a separate return), plus
  • (c)  35% Medicare tax (regular 1.45% Medicare tax + 0.9% additional Medicare tax) on all wages in excess of $200,000 ($250,000 for joint returns; $125,000 for married taxpayers filing a separate return).

For 2017, the self-employment tax imposed on self-employed people is:

  • 4% OASDI on the first $127,200 of self-employment income, for a maximum tax of $15,772.80 (12.40% of $127,200); plus
  • 90% Medicare tax on the first $200,000 of self-employment income ($250,000 of combined self-employment income on a joint return, $125,000 on a separate return), plus
  • 8% (2.90% regular Medicare tax + 0.9% additional Medicare tax) on all self-employment income in excess of $200,000 ($250,000 of combined self-employment income on a joint return, $125,000 for married taxpayers filing a separate return).

There is a maximum amount of compensation subject to the OASDI tax, but no maximum for HI.

Note: On a salary of $127,200 (or more), an employee and his employer each will pay $7,886.40 in Social Security tax in 2017.

Note: A self-employed person with at least $127,200 in net self-employment earnings will pay $15,772.80 for the Social Security part of the self-employment tax in 2016.

Note: Self-employed workers deduct half of their self-employment tax above-the-line in arriving at adjusted gross income.

Information about Medicare changes for 2017, when announced, will be available at www.Medicare.gov. For some beneficiaries, their Social Security increase may be partially or completely offset by increases in Medicare premiums.

Want to discuss how this impacts you and your retirement planning? Contact us for a free consultation.

Matt Leonard

Sep 20
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Retiring? You will spend over $130K on Healthcare!

By Uncategorized

Retiring Workers Will Need $130,000 Just to Cover Health Care, Study Finds

Retirement-Medical-Bills (1)Today’s 65-year-olds can expect to spend an average of $130,000 on health care after retiring, from premiums to co-payments to eyeglasses, according to new estimates. The average single 65-year-old woman can expect to need $135,000 to spend on health care in retirement, while a man will spend $125,000, according to estimates from Fidelity Investments. (The difference is because the woman is expected to live longer — an additional 22 years, vs. 20 years more for the man.) Every year, Fidelity estimates how much it will cost for today’s average 65-year-olds to cover health care expenses for the rest of their lives if they retire now. For a while, it looked as if health care costs were holding steady, but Fidelity this year says couples need to set aside a record $260,000 for Medicare premiums and all other out-of-pocket medical costs — up 6 percent from last year and 18 percent from 2014.

Prime culprits in accelerating health expenses are prescription drugs, especially high-priced specialty drugs, Fidelity says. And as the economy recovers, retirees are using more health care, driving up costs. Fidelity’s estimates, based on an analysis of Medicare’s claims database and trends in survey data, assume that retirees are eligible for Medicare and try to capture all the costs it doesn’t cover — including premiums, co-payments, and things Medicare doesn’t pay for, such as hearing and vision exams. But the estimates are only averages, and people’s costs can vary widely, according to where they live and how healthy they are.

What are the major expenses for retiring that I must plan for?

As retirement approaches, your life’s expenses don’t go away! They remain and now they must be paid on a fixed income. However, the big bills that I get called about are those possibly catastrophic costs associated with paying for the healthcare of a loved one who must reside inside a medical institution/rehabilitation center/nursing home. Family members are shocked with the reality that their existing health insurance will not cover this expense and that couples are left to finance these expenses out of their life savings.

As noted above, the cost for Medicare insurance is projected to cost a person over $130,000 over the remainder of their lifetime. What if you were to learn that you needed to pay that amount PER YEAR to care for a person in a nursing facility. That would certainly change the landscape of everyone’s financial future.

At Rhode Island Medicaid Planning, we discuss the Medicaid program, the program that if your assets and income are within certain limits will pay for the costs of nursing facilities. We discuss the rules and regulations and allow you to make a decision that works best for you and your loved ones.

Source/more: Bloomberg

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Sep 14
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Medicare and Skilled Nursing Facility Care

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Skilled nursing facility (SNF) care

How often is it covered?

Medicare Part A (Hospital Insurance) covers skilled nursing care provided in a skilled nursing facility (SNF) under certain conditions for a limited time.

Medicare-covered services include, but aren’t limited to:

*Medicare covers these services if they’re needed to meet your health goal.

Note

Medicare covers swing bed services in certain hospitals and when the hospital or critical access hospital (CAH) has entered into a “swing-bed” agreement with the Department of Health and Human Services (HHS), under which the facility can “swing” its beds and provide either acute hospital or SNF-level care, as needed. When swing beds are used to furnish SNF-level care, the same coverage and cost-sharing rules apply as though the services were furnished in a SNF.

If you’re in a SNF but must be readmitted to the hospital, there’s no guarantee that a bed will be available for you at the same SNF if you need more skilled care after your hospital stay. Ask the SNF if it will hold a bed for you if you must go back to the hospital. Also, ask if there’s a cost to hold the bed for you.

Medicare-InsuranceWho’s eligible?

People with Medicare are covered if they meet all of these conditions:

Your doctor may order observation services to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you’re getting observation services in the hospital, you’re considered an outpatient—you can’t count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay. Find out if you’re an inpatient or an outpatient.

Here are some common hospital situations that may affect your SNF coverage:

Situation Is my SNF stay covered?
Example #1 You came to the Emergency Department (ED) and were formally admitted to the hospital with a doctor’s order as an inpatient for 3 days. You were discharged on the 4th day. Yes. You met the 3-day inpatient hospital stay requirement for a covered SNF stay.
Example #2 You came to the ED and spent one day getting observation services. Then, you were formally admitted to the hospital as an inpatient for 2 more days. No. Even though you spent 3 days in the hospital, you were considered an outpatient while getting ED and observation services. These days don’t count toward the 3-day inpatient hospital stay requirement.

Remember, any days you spend in a hospital as an outpatient (before you’re formally admitted as an inpatient based on the doctor’s order) aren’t counted as inpatient days. An inpatient stay begins on the day you’re formally admitted to a hospital with a doctor’s order. That’s your first inpatient day. The day of discharge doesn’t count as an inpatient day.

Note

If you refuse your daily skilled care or therapy, you may lose your Medicare SNF coverage. If your condition won’t allow you to get skilled care (like if you get the flu), you may be able to continue to get Medicare coverage temporarily.

Your costs in Original Medicare

You pay:

  • Days 1–20: $0 for each benefit period.
  • Days 21–100: $161 coinsurance per day of each benefit period.
  • Days 101 and beyond: all costs.
Note

If you stop getting skilled care in the SNF, or leave the SNF altogether, your SNF coverage may be affected depending on how long your break in SNF care lasts.

  • If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.
  • If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.
Note

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

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Aug 29
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Medicare and Long Term Care

By Uncategorized

Doesn’t Medicare Pay for Most Long Term Care Needs?

Drawing of Medicare with Stick Men and Clipping PathNo. Even though many people mistakenly believe that Medicare will take care of most long term
health needs, it pays for less than 2% of the cost. A survey conducted by AARP (American Association of Retired Persons) showed that 79% of those expecting to need nursing home care incorrectly believed that Medicare would pay.

 

Medicare will pay for long term care in a nursing home only if the following requirements are met:

A. Skilled care is being provided to the individual in the nursing facility. Skilled care is continuous 24 hour per day care provided by licensed medical professionals under the direct supervision of a physician. Only about ½ of 1% of all nursing home residents receive skilled care. Most residents get either intermediate” (4.5% of nursing home residents) or “custodial” care (95% of nursing home residents).

Intermediate care refers to occasional nursing and/ or rehabilitative care under the supervision of skilled medical personnel. It is often referred to as intermittent care and may include physical therapy, occupational therapy, speech therapy, etc.

Custodial care often involves non-medical personnel such as nurses’ aides who provide assistance with the activities of daily living including bathing, eating, toileting, transferring and dressing.

B. The nursing facility is a “Medicare participating” nursing facility. Many nursing homes will not qualify under this requirement.

C. The nursing home care must follow (within 30 days of discharge) at least a three day hospital confinement. Most often those who require nursing home care do not enter directly after a hospitalization. Often individuals are simply aging and finally realize they cannot manage any more at home or in a relative’s home. Since nursing home confinement frequently does not follow a hospitalization, many states now prohibit prior hospitalization prerequisites in long term care policies.

D. In the past in order for Medicare to pay in a skilled nursing facility, the care the individual received had to be “restorative” in nature. The patient had to be getting better. However, on January 24, 2013, the U.S. District Court for Vermont approved a settlement in the case of Jimmo v. Sebelius which states that Medicare provided skilled care may not always have to meet the expectation of improvement. Generally, if an individual meets the four aforementioned requirements (of skilled care, Medicare participating facility, a 3 day prior hospitalization and care that is “restorative” in nature- now a somewhat unclear term-) Medicare will pay all of the costs of the first 20 days and the individual pays $161 for an additional 80 days (in 2016, adjusted annually). (At a current daily nursing home rate of about $250 or more, one obviously cannot depend on Medicare to pay for most of the cost for these other 80 days.) Beyond day 100, Medicare will pay nothing.

Medicare will pay for long term care in a home health care situation only if the similarly stringent and difficult to meet requirements are met. Home health care coverage includes part-time or intermittent skilled nursing care, physical therapy, and speech therapy, through a Medicare Certified Home Health Care Agency. If the patient requires skilled nursing, physical therapy, and/or speech therapy and if the individual is confined to the home and is under the care of a physician, Part A of Medicare can pay for some other services.

A typical individual who requires nursing home or home health care is someone with a physical disability who simply needs help with the activities of daily living -someone who is simply aging. Medicare will not pay for such custodial care. Alzheimer patients, Parkinsonians, stroke victims, and those who have other organically related mental disorders, form another large group of those who need long term care. Typically, since these chronic ailments of aging don’t “get better,” Medicare benefits are not available.

The bottom line is simple: A wise person will not count on Medicare to pay for long term care services.

So what is a person supposed to do? Contact our office to discuss what long term care planning means to you.

Source: This article is an excerpt from LISI Elder Care Law Planning Newsletter #17 (March 3, 2016)

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Aug 15
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10 Things To Know About Hospice Care

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Learn what Hospice Care means and contains.

Nurse helping elderly man in hospice careDeath comes in many forms. It may arrive suddenly without warning or approach slowly after a long illness. In the latter case, families have time to prepare for the inevitable. What’s more, they may have access to hospice care, which can simplify life by bringing doctors directly to patients and providing myriad support services.

Unfortunately, not everyone who is eligible makes use of hospice. “The truth is half of patients never get hospice at all,” says Joe Rotella, chief medical officer with the American Academy of Hospice and Palliative Medicine. “What we see is patients either avoid hospice or call it very late.”

Some people may not use hospice because they are unaware or misunderstand it. Other times, people may not want to go into hospice because it means ending all attempts to cure a patient. “A lot of times, doctors are reluctant to give up,” says Ellen Windham, author of “Hospice: The Last Responder,” a guide to hospice care.

When the end is in sight, here are:

10 things hospice experts say seniors and their family members should know.

1. Hospice is not a place but a type of care. While it’s true some hospice organizations operate facilities, hospice itself refers to a type of comfort care that can be provided in any setting. “A team of professionals provide emotional and spiritual support to a patient and family anywhere,” says Richard Fife, president of the Foundation for End-of-Life Care.

2. Medicare pays for almost everything. Seniors who receive Medicare will find their hospice care is covered almost completely. That coverage includes everything from doctors and nurses to social workers and homemakers. Patients must pay a $5 co-payment for prescriptions and 5 percent of the Medicare-approved amount for respite care, should they need it. In exchange for this level of coverage, Medicare stops paying for any medical care outside of hospice.

3. You need to have a life expectancy of six months or less. Under Medicare rules, a hospice doctor and a person’s primary care doctor need to certify a person has a life expectancy of less than six months before hospice care can begin.

4. If you live longer, that’s OK. Six months or less is the life expectancy required to enter into hospice, but estimating a person’s lifespan is an imperfect process. “It’s not always easy to predict for a patient with Alzheimer’s, for example, when they’ve entered their last six months of life,” Rotella says. As a result, it’s possible for some people to remain in hospice long after six months have come and gone. Michelle Riddle, a patient advocate at Complete Dignity in Phoenix, says people don’t need to worry about losing their coverage if they do outlive expectations. “If you haven’t passed in six months, they don’t cut you off.”

5. It isn’t only for those with certain illnesses. Some people might mistakenly believe hospice is only for those with certain diseases, such as cancer. However, this type of care can be used by people of all ages with terminal illnesses of any kind.

6. Hospice is about more than medical care. A critical component of hospice is the support services they provide to family members. “Loved ones don’t have to run out to the drug store to get supplies,” Riddle says.

Hospice organizations are available 24/7 with on-call nurses and doctors who can make home visits at whatever time they are needed. Plus, hospice staff coordinates prescriptions, arranges for respite care and meets other needs families might have. Once people are able to stop juggling appointments or worrying about the logistics of their care, they may find their quality of life increases.

“People equate hospice with immediate death, Windham says. However, she advises people enter into this care as early as possible. “Going into hospice sooner rather than later gives patients and family members more quality time together.”

7. Services continue after someone dies. After a person passes away, hospice typically offers grief counseling or other bereavement services to family members. “Many hospitals have a chaplain, but that doesn’t mean you’re going to get the emotional support you get with hospice,” Fife says.

8. You can choose the hospice you want. Hospice isn’t offered by a single entity, but is a form of care offered by thousands of providers. In 2014, there were 4,000 hospice care agencies in the country, according to the Centers for Disease Control and Prevention. “A lot of nursing homes have a hospice they use, but it’s OK to pick a different one,” Windham says. She recommends families interview at least two hospice providers before making a choice.

During those interviews, the most important question may be to ask whether the hospice is Medicare-certified. If not, Medicare won’t pay for its services. Beyond that, patients and families should ask about the type of services provided, frequency of care and who will serve as the family’s point of contact. “If they are getting irritated with your questions, look at a different hospice,” Riddle says. “Don’t be bullied into a choice you don’t want.”

9. More transparency may be coming to hospice organizations. The government doesn’t publish hospice information for consumers as it does for nursing homes. That may be changing, Rotella says. It could be years before it’s fully implemented, but a move is underway for Medicare to publish quality measures of hospice organizations to make the process of selecting one easier for consumers.

10. Hospice is focused on life, not death. Entering hospice might feel like quitting on life, but those who work in the field say accelerating death is not the focus of this type of care. Instead, it’s intended to help people live fully and comfortably in the time they have left.

“[People] think it’s morbid and focused on giving up,” Rotella says. Instead, he says “it’s focused on quality of life while facing the reality of what’s going on with an illness.” Rather than feeling like they are at the mercy of a medical process that entails countless appointments and tests, people in hospice care may finally feel like they are back in control of how they live.

This article was written by Maryalene LaPonsie and can be found here.

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Dec 05
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Leaving Nursing Home During Medicare-Covered Stay

By Uncategorized

LEAVING NURSING HOME WHILE STILL BEING TREATED – IS IT POSSIBLE?

Nursing home residents often want to participate in holiday gatherings but may worry they will lose Medicare coverage if they leave the facility to do so. Residents and their families and friends can put their minds at ease. According to Medicare law, nnursing home residents may leave their facility for family events without losing their Medicare coverage.leaving hospital

However, depending on the length of their absence, beneficiaries may be charged a “bed hold” fee by their skilled nursing facility (SNF). The Medicare Benefit Policy Manual recognizes that although most beneficiaries are unable to leave their facility, “an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care…Decisions in these cases should be based on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences.”

Source: Center for Medicare Advocacy

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