Embracing Elder Care: Exploring Medicare Coverage SNF Benefits

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During Nursing Home Week

As we observe Nursing Home Week, we want to take a moment to acknowledge the dedicated nurses, caregivers, and staff who provide round-the-clock care to our loved ones. This week serves as a reminder of the commitment to ensuring the well-being and comfort of our elderly population. For seniors and their families, understanding how Medicare intertwines with nursing care is crucial for planning and ensuring access to the necessary services.

Medical Coverage for Nursing Home Care

Nursing homes provide a variety of services and personal care assistance. Medicare coverage for nursing homes, however, varies depending on factors like the specific facility, required services, and duration of stay.

Medicare coverage depends on:

  • State and federal laws.
  • National coverage decisions made by Medicare.
  • Local coverage decisions made by companies.

Medicare Part A Skilled Nursing Facility (SNF) Care:

extends coverage for skilled nursing facility (SNF) care under specific conditions. This encompasses a spectrum of services for a limited time, including the following:

  • Hospital inpatient care.
  • Skilled nursing facility care.
  • Nursing home care.
  • Hospice.
  • Home health care.

To qualify for Medicare-covered SNF care, a beneficiary must have undergone hospitalization for a minimum of three consecutive days and necessitate skilled care or rehabilitation services that can only be administered within the confines of a skilled nursing facility. 

Duration of Medicare-Covered SNF Care:

  • Medicare encompasses coverage for up to 100 days of SNF care per benefit period. Nonetheless, coverage extending beyond 20 days mandates the beneficiary to bear a daily coinsurance amount.
  • It’s incumbent upon individuals to familiarize themselves with the criteria governing continued Medicare coverage in an SNF setting, along with the prospective out-of-pocket expenses entailed.

Medicare Advantage Plans (Part C) and Nursing Care:

  • Certain beneficiaries may be enrolled in Medicare Advantage (Part C) plans, which are dispensed by private insurance entities sanctioned by Medicare. These plans frequently encompass coverage for skilled nursing care, albeit the specifics may vary.
  • Beneficiaries enrolled within Medicare Advantage plans should meticulously scrutinize their plan’s coverage nuances, inclusive of any stipulations or prerequisites concerning nursing care.

Long-Term Care and Medicare:

  • It’s imperative to discern that Medicare typically refrains from extending coverage for long-term care in nursing homes for protracted durations. Long-term care requisites, such as assistance with activities of daily living (ADLs) or custodial care, are generally excluded from Medicare coverage.
  • Individuals may find themselves compelled to explore alternative avenues, such as long-term care insurance, In-Home Health Care, or Medicaid, to defray the costs associated with prolonged nursing home stays.

In-Home Health Care: A Viable Alternative: In-home health care provides a valuable alternative for individuals requiring assistance with daily activities after a hospital stay.  This option allows individuals to receive care in the comfort of their own homes, maintaining a sense of independence and familiarity. In-home health care services can include:

  • Meal planning/preparation
  • Assistance with dressing, bathing, toileting
  • Light housekeeping
  • Accompany to doctor’s visits and other appointments

In-home health care plans are available at various levels and do not have age requirements or underwriting, making them an affordable option for seniors and their families. This option is especially beneficial after a hospital stay when care is needed but does not meet the requirements for nursing facility coverage under Medicare. 

Medicare coverage in nursing homes is a vital resource for elderly and disabled individuals in need of skilled nursing care. While it comes with limitations and eligibility requirements, it serves as a crucial safety net for those who might otherwise struggle to afford necessary care. Knowing and exploring your options to receiving care can greatly impact your quality of life and peace of mind.

If you would like more information and guidance on your Medicare coverage, skilled nursing facility benefits, or in-home health care plans, please don’t hesitate to contact our office today at (631) 476-4015 or email us at mlegaspi@imperial-coverage.com.

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Medicare Special Enrollment Periods (SEPs)

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Exploring the 3 Ways You May Qualify

Medicare offers Special Enrollment Periods (SEPs) that allow individuals to enroll in or switch Medicare plans outside of the standard enrollment periods. These SEPs are crucial for individuals who experience certain life events or qualify for specific circumstances. Let’s explore what qualifies you for a SEP and how you can take advantage of them.

Qualifying for a Special Enrollment Period

There are three main reasons why you may qualify for a Special Enrollment Period:

  1. Qualifying Life Events (QLEs): If you experience a QLE, such as moving to a new area, losing health coverage, or other life-changing events, you may be eligible for a SEP.
  2. 5-Star Special Enrollment Period: Medicare rates plans on a scale of 1 to 5 stars, with 5 stars being the highest rating. If a 5-star plan becomes available in your area, you can switch to it during a SEP.
  3. Working Past Age 65: If you delayed enrolling in Medicare because you had employer-based coverage, you have an 8-month SEP to enroll in Medicare once that coverage ends.

Qualifying Life Events and Special Enrollment Periods

If you have Medicare and experience a QLE, you may qualify for a SEP to change your Medicare Advantage or Prescription Drug Plan. These events include:

  • Changing your primary residence
  • Losing your health insurance
  • Being eligible for other health insurance

*Each QLE has a specific timeframe within which you must act to qualify for a SEP. For example, if you move, your SEP is typically 60 days after your move.

5-Star Medicare Special Enrollment Period

If a 5-star Medicare plan becomes available in your area, you can switch to it during the 5-star SEP, which runs from December 8 to November 30 of the following year. It’s important to compare plans to ensure the new plan meets your needs.

Enrollment in Medicaid or Extra Help

Most people with Medicare can only make changes to their drug coverage at certain times of the year. If you have Medicaid or receive Extra Help, you may be able to make changes to your coverage one time during each of these periods:

  • January – March
  • April – June
  • July – September

If you lose benefits from Medicaid or Extra Help, you will have a one-time opportunity to adjust your Medicare Advantage enrollment.

Disenrollment from your initial Medicare Advantage plan

If you initially enrolled in a Medicare Advantage plan upon becoming eligible for Medicare, you have a 12-month window to disenroll from the plan and return to Original Medicare.

If you previously dropped a Medicare Supplement Insurance plan to join a Medicare Advantage plan but now want to switch back, you also have a 12-month period to do so (as long as this was your first enrollment in a Medicare Advantage plan).

Working Past Age 65 and the Special Enrollment Period for Medicare Part B

If you or your spouse work past the age of 65 and delay enrolling in Medicare, you have an 8-month SEP to enroll in Medicare Part B once you retire or lose employer coverage. This helps you avoid late penalties.

Avoiding Gaps in Coverage and Part D Late Enrollment Penalties

To avoid gaps in coverage, enroll in Medicare before you lose employer-based coverage. If you anticipate retiring, contact your employer’s human resources department one or two months in advance to time your Medicare enrollment correctly.

Understanding Medicare Special Enrollment Periods is crucial for individuals to make informed decisions about their healthcare coverage. Whether you’re experiencing a QLE, have access to a 5-star plan, or are working past age 65, knowing your options and timing is key to maximizing your Medicare benefits.

If you would like more information on the SEP, or to find out if you may qualify, please contact our office today and we would be happy to assist you.

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Choosing Your Medicare Advantage Plan: HMOs vs. PPOs

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Choosing the right health plan shouldn’t be complicated. In this blog, we’ll explain the main differences between them, providing insights to help you make informed decisions. Think of this as your handy guide, with essential questions to make your healthcare choices easier and help you confidently pick between HMOs and PPOs.

HMO vs. PPO: What You Need to Know

HMOs are known for being cost-effective with designated provider networks, while PPOs offer more flexibility at a higher cost, allowing you to access out-of-network care. Your choice between the two ultimately depends on your preferences regarding costs and restrictions.

Understanding HMOs:

Health Maintenance Organization (HMO) plans typically consist of an approved network of healthcare providers. In most cases, your medical care is covered only if you visit a provider within the plan network. Going outside this network might mean paying the full cost of services, except in emergencies.

Understanding PPOs:

Preferred Provider Organization (PPO) plans provide you with the flexibility to choose your healthcare provider. Like HMOs, PPOs establish a provider network, usually resulting in lower out-of-pocket expenses when staying within the network. However, partial coverage for out-of-network care is possible, with higher anticipated costs for services beyond the designated network.

Commonalities Between HMOs and PPOs:

Despite their differences, both HMO and PPO Medicare Advantage plans share common ground. They offer the same coverage as Medicare Part A (hospital insurance) and Part B (medical insurance) in a unified plan.

Many Medicare HMO and Medicare PPO plans also include additional benefits beyond what Original Medicare covers.

Key Questions to Consider when choosing between an HMO plan and a PPO plan:

  1. Provider Accessibility:
    • HMO: Do you prefer a plan with a specific network of approved providers?
    • PPO: Is having the flexibility to choose your healthcare provider important to you?
  2. Cost Considerations:
    • HMO: Are you looking for a cost-effective plan with potentially lower out-of-pocket expenses within the network?
    • PPO: Can you afford the higher cost for the flexibility to access both in-network and out-of-network care?
  3. Primary Care Physician Preference:
    • HMO: Do you value having a primary care physician coordinate your care within a network?
    • PPO: Is having the freedom to choose specialists without referrals more appealing to you?
  4. Network Restrictions:
    • HMO: Can you commit to receiving most, if not all, of your care within the plan’s network?
    • PPO: Are you willing to pay higher costs for the flexibility to see providers outside the designated network?
  5. Coverage Beyond Medicare Parts A & B:
    • HMO and PPO: Are you interested in additional benefits beyond what Original Medicare covers, offered by both plan types?
  6. Coordinated Care Preference:
    • HMO: Do you appreciate a team approach to your care within a coordinated network?
    • PPO: Does the idea of having more individual control over your healthcare decisions appeal to you?
  7. Freedom of Choice:
    • HMO: Is having a more structured healthcare experience with a designated network preferable?
    • PPO: Do you value the freedom to seek care from any healthcare provider without network restrictions?
  8. Personal Healthcare Needs:
    • HMO and PPO: When deciding, consider your specific health requirements, provider preferences, and overall comfort level with each plan’s features.
  9. Customer Service and Support:
    • HMO and PPO: What is the quality of customer service for each plan, and how responsive are they to your inquiries?
  10. Travel Considerations:
    • HMO: How does the plan handle healthcare needs when you’re outside the plan’s service area?
    • PPO: Are there additional benefits or coverage when seeking care outside the designated network, especially during travel?

Choosing between an HMO and a PPO requires considering key aspects. By asking these questions, you can pinpoint what matters most to you in terms of cost, flexibility, and healthcare preferences. Your ideal plan is the one that aligns with your lifestyle and budget.

To help you weigh the pros and cons and make a confident decision, download this FREE HMO vs PPO Guide.

Your health coverage should cater to your needs, ensuring you receive the best care for your unique situation.

If you would like additional assistance with plan comparisons, please contact our office today and we would be happy to schedule a review to ensure your Medicare needs are properly in place for 2024.

Resources:

Medicare.gov

www.uhc.com/news-articles/medicare-articles/the-difference-between-medicare-hmo-and-ppo-plans

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What is the Upcoming Medicare GEP?

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If you’re new to Medicare, understanding the various enrollment periods can be a bit overwhelming. With the Annual Enrollment Period (AEP) coming to a close, two crucial enrollment periods are just around the corner: the General Enrollment Period (GEP) and the Medicare Advantage Open Enrollment Period (MAOEP).

Both run simultaneously from January 1st to March 31st.

First, some background. When you are new to Medicare, you have an Initial Enrollment Period (IEP) that runs for a total of 7 months: 3 months before the month you turn 65, the month you turn 65 and the 3 months following that month.

Example: If your birthday is December 3rd, your IEP starts on September 1st and ends on March 31st.

This is the best time to enroll in Original Medicare (Parts A and B together) because you’ll avoid potential penalty fees and delays in healthcare coverage.

However, if you happen to miss your Initial Enrollment Period (IEP), don’t worry. You get another chance each year during the General Enrollment Period (GEP) to sign up for Medicare Part A and/or Part B. During the GEP, you can only enroll in Medicare Part A and/or Part B.

During this time, you cannot:

  • Enroll in a prescription drug plan (Part D)
  • Buy a Medicare Advantage plan (Part C)
  • Change any existing coverage you might have (like going from one Advantage plan to another or dropping Part D)
  • Make any other changes to your coverage

Penalties for Signing Up Late

If you sign up for Parts A and/or B during the General Enrollment Period, you might have to pay extra on your usual premiums – that’s the penalty for signing up late. That’s why it’s a good idea to enroll during your Initial Enrollment Period (IEP).

  • Part A Late Enrollment:

If you need to purchase Part A and miss your first Medicare eligibility chance, your monthly premium may increase by 10%. The penalty lasts for twice the number of years you delayed. For example, if you wait 2 years to sign up, you’ll pay a higher premium for 4 years. Special Enrollment Periods may exempt you from penalties – check your eligibility.

  • Part B Late Enrollment:

You usually won’t face a Part B penalty with a Special Enrollment Period. Expect an extra 10% for each year you could have enrolled but didn’t. Your income may also affect your premium. Learn more about Special Enrollment Periods for your options here: Special Enrollment Periods | Medicare

During the GEP, there is another period called the Medicare Advantage Open Enrollment Period (MAOEP). The main difference between Medicare Advantage Open Enrollment and General Open Enrollment is who can use each one and what changes you can make.

The Medicare Advantage Open Enrollment Period (MAOEP) lets you:

  1. Change Medicare Advantage Plans: You must be already enrolled into a Medicare Advantage plan. If both Medicare Advantage plans are offered in your area, you may change from one to another.
  2. Go Back to Original Medicare: You can drop your Medicare Advantage plan and return to Original Medicare (Parts A and B), with a Part D prescription drug plan. You also have the option to add a Medicare Supplement (Medigap) policy. However, this is not a guaranteed issue. You will most likely have to go through Medical Underwriting.

During this time, You cannot:

  • Enroll in Medicare Advantage for the first time if you are currently on Part A and Part B (Original Medicare).

Understanding and navigating these enrollment periods is crucial for ensuring that you have the right Medicare coverage. If you have any questions or need more information on changing your plan, feel free to reach out to our office today at  (631) 476-4015 and we would be happy to assist you.

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November is Diabetes Awareness Month

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November is a crucial month in the health calendar as it is recognized as Diabetes Awareness Month. This is a time to bring attention to the disease and the millions of people affected by it. It’s also an excellent opportunity for us to shine a light on the importance of health, reminding everyone that your health matters!

  1. Type 1 Diabetes: An autoimmune condition where the body’s immune system attacks and destroys the insulin-producing cells in the pancreas. People with type 1 diabetes need lifelong insulin therapy.
  2. Type 2 Diabetes: The most common form, often linked to lifestyle factors like poor diet and lack of exercise. It results in the body not using insulin properly or not producing enough, leading to elevated blood sugar levels.
  3. Gestational Diabetes: A temporary form that occurs during pregnancy, usually resolved after childbirth, but it increases the risk of developing type 2 diabetes later in life.

Diabetes Management and Medicare: Know the Updates for 2024

One of the most significant challenges for those managing diabetes is the cost of the necessary supplies and medications. However, for Medicare recipients, there will be some important changes starting in 2024 that could make managing diabetes more affordable.

What’s Covered Under Medicare Part B:

  • Injectable insulin used with a traditional insulin pump
  • Insulin used with a disposable insulin pump
  • Diabetes screenings and exams
  • Diabetes self-management training (DSMT) – Medicare may cover up to 10 hours of this initial training – 1 hour of individual and 9 hours of group training. You may also qualify for up to 2 hours of follow-up training in each calendar year that falls after the year you got your initial training.
  • Therapeutic shoes & inserts covered each calendar year:
  • One pair of custom-molded shoes and inserts
  • One pair of extra-depth shoes

Medicare will also cover:

– 2 additional pairs of inserts each calendar year for custom-molded shoes

– 3 pairs of inserts each calendar year for extra-depth shoes

In 2024, Medicare Part B will be extending the $35 monthly co-pay for insulin provided through durable medical equipment (DME). This is a significant improvement that will help many people manage their diabetes more effectively. Furthermore, blood sugar testing supplies will also be available with a $35 monthly co-pay, making it easier to monitor and manage diabetes-related complications.

Medicare Part D Coverage

For those using injectable insulin not associated with a traditional insulin pump or insulin used with a disposable pump, Medicare Part D has got you covered. Additionally, Part D covers certain medical supplies required for insulin injections, including syringes, gauze, and alcohol swabs. Insulin that is inhaled is also covered under Part D.

Starting January 2024, Medicare Part D will extend its coverage to include diabetes-related expenses. Under this plan, individuals can benefit from a $35 monthly co-pay for diabetes medications, and this cost won’t be subject to the plan’s deductible. This expansion is a positive step in making diabetes management more accessible and affordable for Medicare beneficiaries.

Medigap Coverage

If you have Part B and Medigap covering your Part B coinsurance, your plan should cover the $35/month (or less) cost for each covered insulin.

Reversal and Prevention- Keep Diabetes in Check!

Type 2 diabetes, which constitutes about 90-95% of all diabetes cases, is often associated with lifestyle factors. According to the International Diabetes Federation, over 50% of type 2 diabetes is preventable.  It’s essential to address preventive measures and potential reversals for individuals with type 2 diabetes or those at risk. For those with type 2 diabetes or at risk, lifestyle changes play a crucial role.

The 3 pillars to battle Diabetes are Weight loss, adopting a balanced diet, increasing physical activity.

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Navigating Alzheimer’s with Medicare

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September is World Alzheimer’s Month, so we feel it’s vital to equip ourselves, our clients, and community with knowledge about this condition and how Medicare can lend a helping hand.

Whether you’re directly impacted or simply curious, we’re here to provide you with clear, concise information to navigate this journey together.

Understanding Alzheimer’s:

 Alzheimer’s is a progressive brain disorder that affects memory and thinking. It’s common among seniors and can be challenging. But fear not – knowledge is power, and we are here to shed light on what to look for and how to seek help.

Spotting the signs Spotting the Signs:

  • Memory loss disrupting daily life
  • Challenges in planning or solving problems
  • Difficulty completing familiar tasks
  • Confusion with time or place
  • Trouble understanding visual images or spatial relationships
  • New problems with words when speaking or writing
  • Misplacing things and losing the ability to retrace steps
  • Decreased or poor judgment
  • Withdrawal from work or social activities
  • Changes in mood and personality
  • Confusion with time or place
  • Trouble understanding visual images or spatial relationships
  • New problems with words when speaking or writing
  • Misplacing things and losing the ability to retrace steps
  • Decreased or poor judgment

Understanding Your Medicare Coverage and preventative services:

Wondering how Medicare fits into the picture? We’ve got you covered. Discover what cognitive screenings and tests are covered by Part B, and how Part D can assist with certain medications related to cognitive symptoms.

Cognitive Impairment Screening: Medicare Part B provides coverage for cognitive impairment screenings for beneficiaries who exhibit symptoms of cognitive decline or are at risk for cognitive impairment. These screenings can help identify early signs of conditions like Alzheimer’s disease. Your healthcare provider can perform these assessments during your annual wellness visit or at other times when necessary.

Neurological Services: Medicare Part B covers a wide range of neurological services, including consultations and evaluations with neurologists or other specialists. These services are essential for diagnosing and managing conditions affecting brain health.

Alzheimer’s Medications: Medicare Part D, which is the prescription drug coverage portion of Medicare, covers medications used to treat Alzheimer’s disease. Common Alzheimer’s medications, such as cholinesterase inhibitors (e.g., donepezil) and N-methyl-D-aspartate (NMDA) receptor antagonists (e.g., memantine), are often included in Part D formularies. Beneficiaries with Alzheimer’s can enroll in a Part D plan to help cover the costs of these medications.

It’s important to note that specific coverage details can vary depending on your Medicare plan, including whether you have Original Medicare (Part A and Part B) with a separate Part D prescription drug plan or if you have a Medicare Advantage plan (Part C) that may bundle medical and prescription drug coverage. Therefore, it’s crucial to review your plan’s benefits, formulary, and any prior authorization requirements with your Medicare provider or plan administrator to understand the extent of coverage for Alzheimer’s-related services and medications.

Living Well and Planning Ahead:

Living with Alzheimer’s requires adapting to new routines and adjusting. Learn how staying mentally and socially active, maintaining a healthy diet, and engaging in regular exercise can contribute to your well-being. Also, get insights into planning for the future, including legal and financial aspects.

Support for Caregivers:

For caregivers, your role is invaluable. Learn about respite care options covered by Medicare and find out about support groups that can provide guidance and comfort.  Alzheimer’s can have a significant impact on mental health. Medicare covers mental health services, including counseling and therapy, which can be beneficial for individuals with Alzheimer’s and their caregivers.

Local Support Groups: Local Alzheimer’s support groups and community organizations often host informational sessions and provide resources for individuals and caregivers facing Alzheimer’s-related challenges. These groups can offer valuable connections and practical advice.

Join the Movement: World Alzheimer’s Month is a time to raise awareness and show our solidarity. Let’s share information, stories, and encouragement to create a network of understanding and compassion. Together, we can make a difference in the lives of those affected by Alzheimer’s. Stay tuned for more insightful posts throughout this special month. Remember, you’re not alone on this journey – together, we’ll navigate the path ahead.  Please contact us to learn more on preventative care services, and Alzheimer’s medications that may be covered under Medicare Part D.

Alzheimer’s Association: Website: www.alz.org This website is a wealth of information on Alzheimer’s disease, offering resources for patients, caregivers, and those interested in learning more. You can find information about symptoms, diagnosis, care options, and support services.

Medicare Official Website: Website: www.medicare.gov The official Medicare website provides comprehensive information about coverage and benefits for Medicare beneficiaries. You can learn about Medicare Part B coverage for cognitive assessments and screenings, as well as Part D coverage for certain medications related to cognitive symptoms. These resources can offer you detailed information and guidance to help you better understand Alzheimer’s disease and how Medicare can support you or your loved ones.

You can also download this helpful guide for more information.

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