Tag: medicare

Elder Law

The Right to Appeal Has Been Granted to Medicare Recipients

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As of a recent federal court decision, Medicare beneficiaries can now appeal previous patient status decisions.

The Underlying Issue

When Medicare patients go to a hospital, they often enter through the emergency department. The physician who attends to them must decide whether to admit them into the hospital as an inpatient, discharge them, or keep them in the hospital under observation status. A patient under observation services receives care virtually identical to inpatient care but is classified as an outpatient to qualify for traditional Medicare coverage.

If the patient receiving observation services must go to a nursing home to continue their recovery, traditional Medicare won’t cover the nursing home care because they were not classified as an inpatient for at least three consecutive days when they were in the hospital. This can have a serious financial effect on the patient since they must pay for the services on their own. What made the situation worse is that the Centers for Medicare & Medicaid Services would not allow patients to appeal the decision.

Observation Status

A patient in observation status is in limbo since a physician has determined that they are too sick to go home but not sick enough to be admitted into the hospital as an inpatient. They receive basically the same level of care as a patient who is classified as an inpatient, including mental and physical assessments, diagnostic tests, short-term treatments, medications, and feedings.

In 2015, then-President Barack Obama signed the Notice of Observation Treatment and Implication for Care Eligibility Act, a.k.a. Notice Act. The Notice Act requires hospitals to notify patients if they have been receiving hospital services under observation status for more than 24 hours. Patients must be given both written and oral notifications if their observation status exceeds 36 hours.

The written notice must explain why the patient is not classified as an inpatient. It must explain how their observation status may affect the cost of their hospital care and their eligibility for skilled nursing facility care coverage. The written notice must be signed by the patient or someone acting on the patient’s behalf. If they refuse to sign the notice, then a staff member of the hospital must sign it.

Alexander v. Azar

A recent federal court decision in the Alexander v. Azar case sided with Medicare beneficiaries who had been admitted to hospitals as inpatients but then changed to observation status. If you were a patient in a hospital and switched from inpatient status to observation status, you may have the right to appeal Medicare’s decision. To appeal your observation status decision, you must have been:

  • Hospitalized since January 1, 2009
  • A Medicare beneficiary with traditional Medicare (not Medicare Advantage) during your hospitalization
  • Admitted to the hospital as an inpatient before your status was changed to observation status
  • Notified of Medicare Outpatient Observation status from the hospital or have a Medicare Summary Notice stating that you will, or did, receive observation services that are not covered by Medicare part A
  • Qualified for either both Medicare Part A and Part B or only Medicare Part A
  • Hospitalized for at least three consecutive days but fewer than three days as an inpatient
  • Admitted to a skilled nursing facility within 30 days of discharge from the hospital.

Stay up to date as this situation develops by checking in with the Center for Medicare Advocacy.

Help with Medicare and Medicaid

Navigating the complicated Medicare and Medicaid systems can be difficult and time-consuming. It is all too easy to make mistakes that will cause coverage to be denied. An experienced elder law attorney can guide you through the process to get the benefits you need.

We hope you found this article helpful. If you have questions or would like to discuss your personal situation, please don’t hesitate to contact our Reno office by calling us at (775) 853-5700.

Elder Living, Healthcare

Termination of Home-Health Care Services Is Becoming More Common

SchulzeLawGroup

Many Americans are getting their Medicare benefits cut as home health providers, including occupational, speech, and physical therapists, social services, as well as skilled nurses are saying: “Your husband (or whomever) is not going to get better, so we will have to discontinue our services as Medicare will not pay for it.”  Termination of care is swift, often within 48 hours of delivering the message, and the home health care chores fall to the family system or must be paid for out of family funds. So what changed?

PDGM Figure 1

Significant changes began on January 1, 2020, as to how Medicare pays for home health services. Medicare has altered its billing approach from a therapy delivered model (the more therapy you receive, the higher the payments billed to Medicare) and changed it into a reimbursement system known as the Patient-Driven Groupings Model, or PDGM. Medicare Advantage plans have separate rules and are not affected.

The Centers for Medicare and Medicaid Services (CMS) provide Figure 1 as an example of how a 30 day period becomes categorized into 432 case-mixed groups for adjusting payment purchases in the PDGM. These 30 day periods are further broken into the following subgroups: admission sources and timing, twelve clinical principal diagnosis subgroups, three functional impairment levels, and three levels of co-morbidity adjustments. During the 30 days, there is only an allowance for one chosen category under the larger color-coded categories. CMS deems this newer approach to be more holistic regarding patient need assessments.

In 2017, the most recent year for which the data is available, for-profit US home health care agencies (approximately 12,000) provided care to 3.4 million Medicare beneficiaries. Home health rates charged were based on the amount of therapy delivered. The more therapy a patient received, the higher the payout to the agency. Due to the change in payment structure, these agencies are cutting back on therapies provided and even reducing the number of therapists employed. They can’t bill enough to Medicare to remain profitable. These new payment conditions are based on a patient’s underlying diagnosis and other case-specific complicating medical factors. As a result, home health care agencies now have a stronger financial incentive to meet the needs of short-term therapy, post-hospital or rehab facility, as well as caring for patients requiring nursing care for complex situations like post-surgical wounds.

CMS believes this new way to assess payments will strike a balance between costs, efficiencies, needs, and outcomes. The members of the National Association for Home Care and Hospice (NAHC) disagree. Data culled by NAHC from home health agencies indicate there will be a substantial reduction of therapy services offered as a result of the PDGM. William Dombi, the association’s president, states that the cuts “may not be a good move” because medically, patients may deteriorate more rapidly without therapy and seek aid in emergency rooms or hospitals.  He also notes the possibility that if more patients end up worse off and go to emergency rooms or hospitals, that this will reflect poorly on home health agencies and can affect their referrals.

Providing the right patient therapy at the right time by home health care agencies is critical to positive patient outcomes. CMS has done extensive analysis of historical data and, through the use of artificial intelligence tools, feel they can better predict what kind of services and how often a patient will need them through the PDGM. Clarifications are being posted online by CMS that deal with early errors in the program and the ensuing turmoil of therapy provision for patients within the new guidelines. It is the hope that more reviews and revisions to the PDGM will strike a better balance between cost and efficiency, patient therapy needs, and outcomes.

Understanding the role Medicare will play when it comes to long term care services can be confusing. We help families plan for the possibility of needing long term care, and how it could be paid for without causing the family to spend everything they have. If you have questions or would like to discuss your personal situation, please don’t hesitate to contact us. Please contact our Reno office by calling us at (775) 853-5700.

Elder Law, Elder Living

Medicare Scams and How to Avoid Them

SchulzeLawGroup

Insurance companies are frequently subject to being scammed. Scammers frequently target government insurance like Medicare by stealing newly issued medical ID cards and then stealing identities. The Coalition Against Insurance Fraud estimates that tens of billions of dollars are lost annually to these types of fraud. Additionally, medical identity theft is now a top complaint received by the Federal Trade Commission. Billing fraud is also responsible for huge losses to Medicare funds and is difficult to assess as it can be a billing error or intentional fraud.

How does this affect a senior on an individual level? Scammers typically pose as Medicare officials and ask people to pay for their new cards which in reality are free. Or they phone a potential victim with false news of a refund and ask for the person’s ID number and bank account number to deposit the refund. “Right now … everyone is being inundated with TV commercials, brochures, and other official-looking documents in the mail about all the Medicare Advantage plans. It’s so confusing, and in an environment like that, fraud is rampant,” says Micki Nozaki of the California Senior Medicare Patrol. There are more than 50 million Medicare beneficiaries who can annually opt to swap Medicare Advantage and Part D prescription drug plans which provide scammers with the opportunity to prey on vast numbers of seniors.

The Centers for Medicare and Medicaid Services have a list of tips to help prevent fraud. The first and foremost is to protect your Medicare and Social Security numbers vigilantly. It suggests treating your Medicare card like you would a credit card and do not provide the number to anyone other than your doctor, or people you know should have it. Become educated about Medicare with regards to your rights and what a provider can and cannot bill to Medicare. Review your doctor bills carefully, looking for services billed for but not provided to you. Remember that nothing is free with regards to medical care; never accept offers of money or gifts of free services. Be suspicious of your provider if they tell you they know how to “bill Medicare” to pay for a procedure or a service that is not typically covered. Before leaving your pharmacy check to be sure your medication is correct, including the full amount prescribed and whether or not you received a generic or brand name medicine. If your prescription is in error report the problem to the pharmacist before leaving.

Remember Medicare will never visit, call, or email you and ask for personal information such as your Medicare number, Social Security Number, address, or bank account number. Medicare already has this information and does not need you to provide it. Even when Medicare issues new cards that no longer contain your social security number in April of 2019 you will not be required to do anything. You can assume that anyone who claims to be helping you with Medicare and asks for your personal or financial information is a scam artist so close the door, hang up the phone, or delete the email.

When it is time to compare plans be sure to meet with a trustworthy advisor. Some insurance representatives give the industry a bad name by selling you a policy or plan that does not suit your needs or your budget. Some agents go so far as to ask you to sign a release form allowing them to make decisions on your behalf. Never sign anything related to Medicare without first reading it carefully. Additionally, it is a good practice to have a family member or lawyer review the document before signing it.  The non-profit National Council on Aging (NCOA) has a free, brief assessment that allows you to compare plans online. You can also contact your local State Health Insurance Assistance Program (SHIP). SHIP is a provider of free, federally-funded Medicare counseling via a trained volunteer or staff member.

Medicare fraud wastes billions of taxpayer dollars annually. Carefully review your medical bills and have inaccuracies corrected. Guard your personal information vigilantly and be wary of people asking you to provide that information. Meet with a trusted insurance advisor or compare medical plan options using the sites listed above. If you are unsure about something call Medicare directly for clarification.

If you have questions or would like to discuss anything you’ve read, please don’t hesitate to contact us. Please contact our Reno office by calling us at (775) 853-5700 with any questions.

Elder Living, Healthcare

Don’t Wait for a Crisis to Discuss Long-Term Care With Your Parent

SchulzeLawGroup

It is unclear whether or not your parent has a plan in place for long-term care. It is a difficult topic to broach; no one wants to talk about death and the financial realities that come with aging.  Instead of having a proactive conversation early in a parent’s aging process, most families have a reactive discussion under high levels of stress and emotions while their parent is experiencing an adverse health event.  The Public Broadcasting Service (PBS) has reported that 85 percent of the time long-term care decisions are made during a medical crisis. The message is clear, be proactive and start discussing the important financial questions with your parent.

Prepare Yourself

Your parent will feel more comfortable and at ease if you have processed your feelings before talking to them.  Conduct research so that you are knowledgeable enough to present a clear and concise set of options for your parent.  Having options allows your parent and family to make decisions and feel in control of the process.  You are seeking progress, not perfection. It may not all become settled in one conversation, but the price of silence about your parent’s plan may be very costly to you.

Review Documents

Two of the most critical personal legal documents are a durable power of attorney (DPOA) and a healthcare proxy. All older adults should have these documents as it gives legal authority to a designated representative to make financial, legal, and health care decisions on your parent’s behalf. If your parent does not have a DPOA and becomes incapacitated, you will have to go to court to get appointed as your parent’s guardian which can be a complicated legal process at a time when your energy is better spent in the care and decision making for your parent. If they do not have a DPOA and health care proxy in place make arrangements for them to meet with a trusted elder law attorney to properly draft the legal documents.

Often a parent will have a will, retirement account information, and insurance policies that have not been revisited or updated in years, sometimes decades. When was the last time your parent reviewed beneficiary designations? Family circumstances change, and the birth of a child, death, or divorce can affect how your parent may want beneficiaries designated. It is best to review financial and insurance data annually with your parent and make adjustments if necessary. For example, if the parent’s children are grown it might be best to cut back on the amount of life insurance they carry to save money on annual premiums.

Long Term Care Plan

Address the issue of long-term care. According to the PBS, a full 70 percent of all seniors will need some long-term care as they age. Even if your parent is healthy today odds are they will require long-term care and the costs are staggering. Some life insurance companies will add a long-term care rider to an existing policy. Medicaid also can cover some long-term care costs, but neither standard health insurance nor Medicare will cover your parent’s long-term care expenses.

Meet the Team

Ask your parent about their financial advisors and request a brief introduction to them.  Find out who they are and how you might contact them in the event your parent is unable to do so. This information will allow you to keep an eye on your parent’s accounts and be confident the advisors are trusted, objective, and well versed in elder financial issues. Oversight by you in a slightly detached way provides your parent privacy and independence about their finances but allows you to protect them from unscrupulous advisors. 

Understand Filing System

The last thing you need to discuss is where this vital information is filed so that before a crisis hits you know where to find the important documents, online passwords, and forms of ID you will need to facilitate your parents well being. While you do not have to see all the specific contents of the information, particularly the financials, knowing where they keep the data is critical in a crisis. Remember that as your parent ages they may start to change the location of the information. Check with them a couple of times a year to ensure the information is still in the same place and physically look to be sure it is.

Discussing your parent’s strategy is best begun while they are healthy.  Proactive planning is the best way to help your family as your parents age.  Contact our office today and schedule an appointment to discuss how we can help you and your family.

Elder Law, Healthcare

Tips for Understanding Medicare

SchulzeLawGroup

Navigating Medicare can sometimes seem like going through a maze. On the one hand, Medicare is obviously a good resource because it provides medical benefits to seniors who are often on a fixed income. On the other hand, however, navigating the ins and outs of Medicare can be seriously confusing, causing many to give up in exasperation. If you are a senior and in need of medical care do not despair—there are numerous resources available to help you navigate the complicated details and minutiae of Medicare.

  • Consider hiring a qualified local elder law attorney sooner than later. Their professional knowledge of the ins and outs of the Medicare system combined with their experience working with senior citizens allows you to get the help and coverage you need as quickly as possible.
  • There are multiple websites you should check out. Medicare.gov, the official site of Medicare should be a starting point, as it provides numerous facts on the program and allows you to search for providers. The Social Security Administration website also has information on Medicare eligibility and enrollment. These are just two, but you can perform an Internet search on Medicare information and you will receive a list of several sites to review.
  • If you are uncomfortable working with computers it would be in your best interests to ask a friend or relative to help you because some of the information on the internet is very valuable. However, for those who would rather talk to a person, you may call 1-800-MEDICARE (800-633-4227) for more information.
  • Another great resource is the American Association for Retired Persons, commonly known as AARP. AARP is a well-established advocate for senior citizens in the United States. The organization offers helpful, reliable resources such as Information-packed webinars featuring experts who can break down some of the Medicare facts that applicants need to know.
  • There also may be support available at the state level like State Health Insurance Assistance Programs, or SHIPs. These programs offer free counseling for seniors who receive Medicare. Medicare applicants and their loved ones should visit shiptacenter.org for more information.

But if you want to save yourself hours of confusing computer research and potential headaches, the best idea is to speak with an experienced local elder law attorney before the Medicare application process even begins. A good elder law attorney can assist you with the complex process, ensuring that you get the benefits you are entitled to more quickly. If you have questions or would like to discuss your personal situation, please don’t hesitate to contact us. Please contact our Reno office by calling us at (775) 853-5700.

Healthcare

How Telehealth Services are Growing Coverage on Medicare

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The Centers for Medicare & Medicaid Services (CMS) recently announced, in response to the COVID-19 outbreak, an increase of access to Medicare telehealth services. This means that Medicare beneficiaries can receive more benefits from their doctors without having to travel to a healthcare facility.

The terms “telehealth” and “telemedicine” refer to the ability to exchange medical information from one site to another through electronic communication to improve a patient’s health.  With the rapid rise of COVID-19 cases, there is the urgency to expand the use of technology to help people who need routine care. Telehealth will keep vulnerable beneficiaries and those with mild symptoms in their home, but with access to the care they need by phone and video rather than requiring an office visit.

Prior to this change, Medicare would only pay for telehealth on a limited basis, and only for persons in a designated rural area. Now Medicare beneficiaries will be able to receive the following services through telehealth: common office visits, mental health counseling, and preventive health screenings. This will help keep more of the at-risk population (Medicare beneficiaries) able to visit with a doctor from home, rather than traveling to a doctor’s office or hospital which puts the beneficiary and others at risk. Telehealth visits will be treated the same as regular, in-person visits and will be paid by Medicare at the same rates.

These changes go into effect for services starting March 6, 2020, and will continue for the duration of the COVID-19 Public Health Emergency. For more information, view the fact sheet prepared by CMS.

Better access to telehealth is a big step in getting Medicare beneficiaries appropriate care in the least restrictive way If you have questions, please do not hesitate to contact our Reno office by calling us at (775) 853-5700.

Uncategorized

Giving Gifts While on Medicaid Can Be Risky

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Mabel’s children were concerned that Mabel would need long-term nursing-home care in the near future. It was the holidays, and Mabel always got a lot of joy out of generosity. But her children had heard that people in Mabel’s circumstances should not give gifts.

The concern is real. For Medicaid to cover the huge expense of nursing-home care, Mabel would have to show that she owned nothing more than around $2,000. And she must also show that she had not given away money or assets over the prior five years (2.5 years in California). That Medicaid rule – the “look-back period” or the “transfer penalty” – would charge Mabel dearly for her generosity. Depending on the size and number of gifts, the penalty could be substantial.

Many wrongly think that there is no penalty for gifts of up to around $15,000 annually. That misunderstanding confuses tax law with Medicaid law (and it also misstates tax law, but that’s another subject). The Medicaid rules are entirely different from the tax rules. In the Medicaid context, gifts of any amount that are given during the look-back period can be penalized.

There are exceptions. These include gifts to spouses and siblings under certain circumstances, disabled children, and children who are caregivers and who live at home with the elder for a span of time. But overall, gifts and Medicaid do not go together. The Medicaid rules are complicated and the consequences for mistakes can be very costly. There are a number of options to protect assets and still qualify for benefits, but these options must be weighed with great care. This is why it’s best to consult attorneys who, like us, are qualified by experience and expertise in Medicaid law.

There is one harmless deception Mabel’s children might consider, to keep Mabel happy and still satisfy the Medicaid rules. The children might help Mabel fill out checks for all the gifts she’d like to give, together with a greeting card for each gift. Everybody could thank Mabel, tear up the check later, and tell her what they “bought” with that amount. It may be that that little device would be worth it, so Mabel could enjoy the holidays too.

Otherwise, the sooner you consult a qualified elder law attorney, the more other options may be available. If we can be of assistance, please don’t hesitate to reach out for a consultation.

Uncategorized

Medicare Launches App to Help Beneficiaries Find Out What’s Covered

SchulzeLawGroup

At the doctor’s office and want to know if a procedure is covered by Medicare? There is an app for that. Medicare has launched a free app that gives beneficiaries a quick way to see whether the program covers a specific medical item or service. 

The “What’s Covered” app allows you to search or browse to learn what’s covered and not covered under Medicare Parts A and B, how and when to get covered benefits, basic cost information and other eligibility details. You can also see a list of covered preventive services.  The app does not give results for extra benefits that Medicare Advantage plans may cover but that Original Medicare does not, such as certain vision, hearing or dental benefits. 

Examples of the types of questions the app can answer include:

               When are mammograms covered?

               Is home health care covered?

               Will Medicare pay for diabetes supplies?

               Can I get a regular cervical cancer screening?

               Will my Medicare benefits cover a service to help me stop smoking?

Although the app provides beneficiaries with basic information, it doesn’t provide personalized information. It doesn’t ask details about each user’s specific insurance information, so it doesn’t take into account the user’s supplemental insurance, co-insurance, and deductibles. Essentially, the app provides another way for Medicare beneficiaries to get the same information that is available online and in the Medicare handbook.

The app is part of an initiative by the Centers for Medicare and Medicaid Services (CMS) focused on modernizing Medicare and empowering beneficiaries. Other initiatives include:

  • Enhanced interactive online decision support to help beneficiaries better understand and evaluate the coverage options and costs of original Medicare compared to Medicare Advantage plans.
  • New price transparency tools that let consumers compare the national average costs of certain procedures between settings, so people can see what they’ll pay for procedures done in a hospital outpatient department versus an ambulatory surgical center. 
  • A new webchat option in the Medicare Plan Finder.  
  • New easy-to-use surveys across Medicare.gov so consumers can tell CMS what they want.

To get the new “What’s Covered” app, go here: https://www.medicare.gov/blog/whats-covered-mobile-app.