Wanderpolo & Siegel, Counselors at Law

Medicare Open Enrollment Ends December 7-Don't Miss Out

My elder care coordinator, Lori Kayne, and I recently went to see new clients.  A charming couple, 88 and 91 years old, they both struggled with substantial health issues. Yet, they were still in a Medicare Advantage Plan. These managed care plans, otherwise known as Medicare Part C,   offer many advantages for healthier seniors. They have minimal co-pays and deductibles and generally cover services that traditional Medicare does not. 

However, Medicare Advantage plans are run by private insurance companies and they are managed care plans which means they restrict your choice of providers.  This can be especially problematic when you need a specialist.  We have also found that our clients who have Medicare Part C have quite limited choices when it comes to picking the rehab facility to go to after a hospitalization.  In addition, our experience is that managed care plans tend to cut off rehab stays quicker than the provider would themselves. With Part C, the insurer decides,  whereas with traditional Medicare the facility makes the initial decision when they think Medicare will no longer cover the patient. For this reason, we often recommend that our clients consider switching back to Medicare Part A and B when they need long term care.

Of course, that switch can only be made under special circumstances or during Open Enrollment.    We are in the midst of Open Enrollment now which allows beneficiaries to switch between plans, add or drop Part D, move from traditional Medicare to Advantage or the reverse. There are many professionals who can help you consider your options given your specific health situation for free. Just remember you must make any changes by December 7th.

 

 

Disadvantages of Medicare Advantage Plans

Not all nursing homes are equal. Some have much higher rates of re-hospitalization than others or just do a generally better job at providing good outcomes for residents. Recently, some researchers looked at the quality of care that traditional Medicare enrollees receive versus Medicare Advantage enrollees as ElderLawAnswers discusses in "Are Medicare Advantage Plans Steering Enrollees to Lower-Quality Nursing Homes?"

It turns out that Medicare Advantage enrollees, on average, enter nursing homes that score worse on quality control metrics than traditional Medicare enrollees.  Advantage Plans also often limit which rehab facilities their enrollees can go to. This is why we generally suggest that our clients switch to traditional Medicare if they need long term care. You want to choose your long term care facility based on its quality, cost, location and other factors that are important to you, not because your insurer says you have to go there. 

 

Being Under Observation in the Hospital

Many elderly people face huge medical bills for rehab stays because of how they are classified during their hospitalization. This makes a big difference in how much Medicare will pay.

When an elderly person has an extended stay in the hospital, they are almost always under the impression that Medicare will cover most of the costs. However, seniors can be hospitalized for several days and only later discover that they were never actually admitted.

 

If the patient is in the hospital "under observation" they are still considered to be outpatients, no matter how long they are actually in the hospital.

This issue has been reported in The New York Times in "Under 'Observation' Some Hospital Patients Face Big Bills."

Elder law advocates have long advocated for changes in the Medicare rules that allow this practice.  It is particularly problematic for individuals who need post-hospital rehab care which is only covered with a qualifying hospital admission.  Often seniors do not realize that their rehab stay will not be covered until it is too late. 

A class action lawsuit is now pending to address this problem. Hopefully it will put an end to abuse of observation status.

Reference: New York Times (Sep. 1, 2017) "Under 'Observation' Some Hospital Patients Face Big Bills."