Preparing for Medicare Open Enrollment

Oct. 15 marks the start of Medicare's seven-week annual election period, when current beneficiaries can add, drop or switch prescription-drug plans and make other coverage changes.

In Medicare, individuals must choose one of two paths: original fee-for-service Medicare, or a federally subsidized Medicare Advantage plan, which typically operates like a health-maintenance or preferred-provider organization. Many who opt for traditional Medicare also purchase a private "Medigap" policy, as well as a separate prescription-drug policy, to patch holes in their coverage.

In recent years, Medicare Advantage plans have gained in popularity, in part because, when compared with a Medigap policy, they generally cover a wider array of benefits, often including prescription drugs and dental care. Many also charge lower premiums, but require members to use the plan's network of providers.

The Affordable Care Act has sparked fears that Medicare Advantage plans, which cover about 30% of Medicare beneficiaries, will raise premiums, reduce benefits and pare their networks of doctors and hospitals. The reason: Under the law, Medicare will reduce payments to Medicare Advantage plans by some $156 billion by 2022, to bring per-person payments in line with those of traditional Medicare.

Citing the ACA, the nation's largest Medicare Advantage insurer, UnitedHealth Group, has cut an estimated 10% to 15% of the doctors and hospitals from its nationwide network. Consumer advocates say the insurer targeted providers with the sickest and most expensive patients, leaving patients in the middle of treatments in the lurch. The company says the changes enable it to better coordinate care and denies that patients in the middle of treatments are adversely affected, extending exceptions to members in active treatment.

Because some of the cuts occurred at times of the year when patients are unable to switch plans, Sen. Sherrod Brown (D., Ohio) and Rep. Rosa DeLauro (D., Conn.) recently introduced legislation that would bar insurers from dropping providers outside of Medicare's annual open-enrollment period.

Because Medicare Advantage can change annually, it's important to examine your options during open enrollment, from Oct. 15 to Dec. 7.  You should call your providers to make sure they still participate in your plan.  You can also use the "Plan Finder" tool at medicare.gov to compare premiums, copayments and deductibles for Part D prescription-drug plans in your area.

During open enrollment, you can switch to either a Medicare Advantage plan or to traditional Medicare, which allows you to see any doctor who takes Medicare. From Jan. 1 to Feb. 14, Medicare Advantage participants may switch to traditional Medicare.

Medicare beneficiaries whose claims are denied should also know that, despite rising backlogs in Medicare's appeals system, two recent lawsuits indicate that those who press their cases have a good chance of success. The procedure differs depending on whether you're in traditional Medicare, a Medicare Advantage plan or a Part D prescription-drug plan. Typically, each appeal can be heard five times, the last time in a federal court.

Since 2010, success rates in the first two rounds of appeals of denied claims for home health-care coverage have plunged to 5% or less, according to a class-action lawsuit the nonprofit Center for Medicare Advocacy in Willimantic, Conn., filed on June 4 in the U.S. District Court in Connecticut against the Department of Health and Human Services, which oversees the agency that administers Medicare.

The center's director of litigation, Gill Deford, told the Wall Street Journal that consumers who want a "meaningful review of their Medicare claims" should continue to the third round of appeal—before an administrative law judge—where odds of success jump to 40% or more.

The average wait for a decision from an administrative law judge is 398 days, up from 95 days in 2009, according to HHS. In a federal lawsuit filed Aug. 26, also in Connecticut, the Center for Medicare Advocacy seeks to force the government to take steps so that appeals can be decided within the 90 days the Medicare statute requires.

When appealing, ask your doctor for a letter explaining why you need the treatment in question. Those who go before an administrative law judge may benefit from retaining a medical or legal advocate. Most State Health Insurance Assistance Programs provide free counseling.

This post is based upon a Wall Street Journal article which can be read here.

What Happens When We All Live to 100?

Gregg Easterbrook, contributing editor of The Atlantic has penned an excellent and thought-provoking article in What Happens When We All Live to 100? (the pictures accompanying the article are equally excellent):  

For millennia, if not for eons—anthropology continuously pushes backward the time of human origin—life expectancy was short. The few people who grew old were assumed, because of their years, to have won the favor of the gods. The typical person was fortunate to reach 40.

Beginning in the 19th century, that slowly changed. Since 1840, life expectancy at birth has risen about three months with each passing year. In 1840, life expectancy at birth in Sweden, a much-studied nation owing to its record-keeping, was 45 years for women; today it’s 83 years. The United States displays roughly the same trend. When the 20th century began, life expectancy at birth in America was 47 years; now newborns are expected to live 79 years. If about three months continue to be added with each passing year, by the middle of this century, American life expectancy at birth will be 88 years. By the end of the century, it will be 100 years. 

Viewed globally, the lengthening of life spans seems independent of any single, specific event. It didn’t accelerate much as antibiotics and vaccines became common. Nor did it retreat much during wars or disease outbreaks. A graph of global life expectancy over time looks like an escalator rising smoothly. The trend holds, in most years, in individual nations rich and poor; the whole world is riding the escalator.

Projections of ever-longer life spans assume no incredible medical discoveries—rather, that the escalator ride simply continues. If anti-aging drugs or genetic therapies are found, the climb could accelerate. Centenarians may become the norm, rather than rarities who generate a headline in the local newspaper.

Pie in the sky? On a verdant hillside in Marin County, California—home to hipsters and towering redwoods, the place to which the Golden Gate Bridge leads—sits the Buck Institute, the first private, independent research facility dedicated to extending the human life span. Since 1999, scientists and postdocs there have studied ways to make organisms live much longer, and with better health, than they naturally would. Already, the institute’s researchers have quintupled the life span of laboratory worms. Most Americans have never heard of the Buck Institute, but someday this place may be very well known.

To read the rest of this fantastic article, go here. 

Salvation Army: Partners in Caring

I just received my annual "thanks" for supporting the Salvation Army.

Your compassionate support is providing struggling families with food, clothing, shelter and much-needed hope. Thank you!

You are having a tremendous impact in our community! Through your concern and generous support of The Salvation Army, you are reaching out to our neighbors in greatest need.

Thanks to you, hungry children are being fed. Families are finding safe shelter. And people in crisis are being helped back on their feet.

This past year you have helped us reach out with:

• Food services for the hungry

• Nights of safe shelter

• Disaster Emergency help for families in need

• Clothing and furniture distributions for the less fortunate

• Counseling and spiritual direction for lost souls.

And so much more, more than we can count. Thank you so much!

Of course, no thanks is necessary.  I have witnessed first hand the difference this fine organization makes, and have  testimony in abundance from clients and friends recounting the beneficial efforts of the Army of volunteers.

It strikes me though, that I never see slickly produced commercials by the Salvation Army tugging at my heart-strings, asking me to adopt a child, a pet, a family, or a community.  I can recall no television or radio advertisement with the haunting voice of a popular singer rising and falling as a voice-over urges me to donate and "donate now."

I cannot recall the Salavation Army paying to sponsor a sports event,  professional sports franchise, concert, or music festival as have so many other charities.  Yet the Army continues to wage war against poverty, hunger, homelessness, substance addiction, and to fill physical, and spiritual needs.

My wife and I have numbered as amazing clients three who owe their very lives to the Salvation Army.  One family recounted to us how, following WWII, their entire family and community in Eastern Europe were dispossessed of home, property, and wealth- for being German.  Despite that these families had no ties or connection to Germany for five generations before the war, Germanic names were despised after the war. The fact that the patriarch of the family had died fighting Nazi Germany alongside the rest of the free world saved these families for a time, but the service was soon forgotten and they were made refugees. But, there were no aid programs, and traditional charities refused to help.  The Salvation Army, however, came to the rescue.  The family recounted an eerie and ironic journey by train during which Jewish refugees and Christian refugees shared the similarities of their plight as they were rescued from Eastern Europe, some to ultimately reside in Akron, Ohio.

The family serves the Army to this day.

A Dutch family described a. similar situation in a more recent time.  Political upheaval in Central America stranded their father.  The company for whom he worked maintained kidnapping insurance, and often retained experts to rescue kidnapped employees, but because their father was not kidnapped, they simply abandoned him.  Working through local churches in the region, the Salvation Army was able to rescue those otherwise trapped and abandoned.

The Salvation Army does amazing work.   

You can help.  Consider a donation here. 

    

New Regs May Increase Pay for Home Care Workers, Which Might Harm Seniors and Others

A federal regulation scheduled to go into effect on January 1, 2015, could force employers to pay previously exempt caregivers the federal minimum wage and time-and-a-half for overtime.  While this may seem like a good deal for the caregivers, it could result in cutbacks to services for seniors and people with disabilities if states limit caregiver hours in response to the new regulations.

Congress initially passed the Fair Labor Standards Act (FLSA) in 1938 to give most workers a guaranteed minimum wage and overtime protection.  The original FLSA did not apply to many domestic workers hired directly by households, so in 1974 Congress amended the FLSA to cover many people who work in private households.  However, the 1974 amendment did not apply to "companionship" workers who assist elderly patients or people with disabilities, and it also stated that live-in domestic workers were not entitled to overtime pay.

In 2013, the Department of Labor issued a final regulation altering these rules for the first time since 1974.  The new regulation, which goes into effect on January 1st, narrows the definition of "companionship" services and requires third-party employers like home health care agencies to meet all minimum wage and overtime laws for all employees. 

Under the new rules, an employee qualifies as a "companionship" worker only if he spends less than 20 percent of his work time assisting a senior or person with disabilities with activities of daily living or instrumental activities of daily living.  In addition, if the worker provides any medically necessary services, then he is not engaged in "companionship" work.  In all cases, if the employee is not considered a companion, then he must be paid the minimum age and must receive overtime pay.  These exceptions from minimum wage and overtime rules apply only to workers employed by the senior, person with disabilities or his or her household.  If the worker is employed by a third party, or in many cases if the worker is employed by both the person with disabilities and a third party (like a state agency), then he will always be subject to minimum wage and overtime rules, even if he is a live-in employee who would typically not be subject to overtime rules, and even if the only service performed is companionship.

Although the new regulations could mean more money for caregivers who may not currently receive minimum wage or overtime protection, there could also be some negative consequences for consumers and caregivers.  Since many state agencies are now going to be considered third-party employers, they may implement their own regulations limiting the number of hours that caregivers can work in order to avoid being out of compliance with these new federal rules.  This could lead to reduced services for people who need them and fewer hours for caregivers.  Of course, limitations upon such services can mean that many seniors are left without an alternative to institutional care.

These new rules also further complicate the decisions of a senior directly employing caregivers.  In addition to increasing the actual cost of care, the regulations will likely reduce the the planning flexibility of caregivers and their employers.  A family that requires a caregiver for ten hours a day, for example, might be forced to retain two caregivers instead of one, in order to avoid the additional cost of overtime, and to comply with limitations of hours.  These complications may make the goal of "aging in place" even harder to achieve.

According to an advocacy fact sheet from the National Senior Citizens Law Center, only California has addressed these concerns in its 2014-2015 budget, which leaves most seniors and people with disabilities in limbo as the January 1st implementation deadline approaches.

For more on this complicated problem, you can view an assortment of materials on the Department of Labor's website here and download the National Resource Center for Participant-Directed Services' toolkit here.

Medicare Increases Coverage of Mental Health Services

Medicare has increased the amount of mental health coverage beneficiaries are entitled to. After years of unequal treatment, Medicare now covers mental health care the same way it covers physical illnesses.

Previously, Medicare covered only 50 percent of the cost of mental health treatment. In 2008, Congress passed a law that required Medicare to gradually begin covering a greater portion of the cost until it was equal to the amount Medicare pays for outpatient medical care.

In 2014, Medicare began covering 80 percent of the approved amount for outpatient care, including visits to psychiatrists and licensed drug and alcohol counselors. Beneficiaries will still have to pay any applicable deductibles and coinsurance amounts. These new coverage rules apply to Original Medicare only. Individuals covered by a Medicare Advantage plan may have different costs and rules. 

Medicare still puts a cap on inpatient mental health coverage, paying for no more than 190 days of inpatient psychiatric hospital services during a beneficiary’s lifetime.

For more information on Medicare's coverage of mental health, click here.