Insurance

On Aug. 1, 2016, the Ohio Department of Medicaid drastically changed eligibility rules for Medicaid serving people who are disabled and people who need long-term care.

These changes will affect people at the time they need/want Medicaid coverage and make it even more important for people to think ahead about the time that they will need long-term care.

TOO MUCH INCOME

Those are weird words to write: too much income. However, in the weird world of Medicaid for long-term care, they are real. Anyone with gross income above the Special Income Level (currently, $2,199.00 per month) triggers a new requirement in Ohio’s Medicaid rules on how the so-called “excess income” must be handled each month.

Income above $2,199 must be transferred from the person’s account(s) into a separate account in the name of a Qualified Income Trust (also known as a QIT or Miller Trust).

Money in a Miller Trust must be paid out each month as part of the person’s share in his long-term care costs. The amount of money that the person spends and the amount that the person keeps are the same under the new rules as they were under the old rules.

KEEPING OR SELLING THE HOUSE

Under Ohio Medicaid’s old rules, a single person applying for Medicaid for nursing home or assisted living costs had 13 months after the beginning of eligibility during which to decide whether he couldreturn home. If unable to return home, then the Medicaid recipient had to put his house up for sale by the end of month 13. While the house was for sale, Medicaid eligibility would continue.

Under the new rules, a single person cannot automatically wait for 13 months. The person must either make a written declaration that he intends to return home, or the house must be sold.

For you pros at Medicare open enrollment, you know that this is when you review your Medicaid Advantage Plan, Supplement and Drug plans to make sure you are set for another year.

For newbies, there are some legal issues regarding Medicare coverage that don’t get much publicity but are very important.

SKILLED NURSING AND WHAT’S COVERED

Many people incorrectly think that Medicare won’t pay much for skilled care such as rehabilitation, therapy, wound dressing and other daily health needs in a skilled facility or at home. Services and Medicare billing are stopped quickly because they think that Medicare will not pay anymore if the patient is not showing “improvement” or he “fails to progress.” This idea has become pervasive in health care, and people simply accept it as the law.

However, “improvement” is not the standard by which Medicare can stop paying for skilled nursing care; it never has been. A 2011 federal class action lawsuit against Medicare was filed to help clarify coverage for millions of seniors. The government settled the case in 2012 by agreeing that under federal law people cannot be denied coverage for skilled care just because they have reached a plateau and are not improving.

Coverage is necessary if the person needs skilled care to maintain his or her condition, prevent complications or to not backslide. This is a maintenance standard, not an improvement standard.

Medicare also was required to educate all seniors receiving Medicare and all Medicare skilled care providers about the corrected policy. The Centers for Medicare and Medicaid (CMS) agreed to do so.

In 2014, they released instructions and updated Program Manuals for Medicare billing and appeals agencies. They issued a fact sheet to inform providers and the public about the change. They were supposed to spot check nursing homes, home health care agencies and other providers to make sure they were using the correct standards.

You signed up for Medicare when you turned 65. Like most people, you probably breathed a sigh of relief, thankful that your health insurance decisions were settled.

But wait — not so fast. Didn’t any- one tell you about Medicare Open Enrollment?

Confused? So is everyone else.

Never heard about Medicare’s Open Enrollment period? If you are over age 65, you’ll soon find your mailbox jammed with official-looking envelopes from insurance companies competing for your attention. While it might be bewildering, it can also mean good news for you.

Many people find their initial enrollment in Medicare to be overwhelming. They often make mistakes. They may pick a plan that doesn’t cover the doctors or hospitals they prefer. Maybe there is a change in health or they chose a prescription drug plan that doesn’t cover their prescriptions. For whatever reason, they find they are locked into insurance coverage that simply does not fit their needs.

Medicare’s open enrollment is a chance for a do-over. It is an annual opportunity to take a close look at all the other Medicare health insurance options. It’s your chance to make changes that benefit you. Medicare’s open enrollment period begins every year on Oct. 15 and closes Dec. 7. During this period, people who have previously signed up for Medicare can:

• change from Original Medicare to a Medicare Advantage plan

• change from a Medicare Advantage plan back to Original Medicare

• switch from one Medicare Advantage plan to a different Medicare Advantage plan

• join a Medicare prescription drug plan

• switch from one Medicare prescription drug plan to a different Medicare prescription drug plan

• drop Medicare prescription drug coverage completely

Any changes made during this open enrollment take effect Jan. 1 of the following year.

WHERE TO BEGIN

Those covered by a Medicare Advantage plan or Prescription Drug plan will receive an Annual Notice of Change from their insurer outlining changes to their plan for the following year.

When you reach age 65, whether you are still working or took an early retirement, it’s time to educate yourself about Medicare.

“Medicare is a health insurance option that individuals have available to them when they are turning 65 or have been on disability for 24 months,” says Kathy Hirko, owner of KAZ Company in Independence, a business that helps people understand Medicare coverage plans.

Health care, in general, is confusing to most people — and Medicare is no different. Hirko provides some basics when venturing into the process.

CHOOSING YOUR PLAN

If you are collecting Social Security benefits and have turned 65, you might have already received your Medicare card.

There is an opportunity to enroll in Medicare three months before or after your 65th birthday. To apply for your benefits, contact Social Security by either phone, online or go to the local office.

There are different plans (A and B) for Medicare that cover 80 percent.

“You are paying into Medicare as you work,” Hirko says. “Part A (hospital coverage) is free to anyone who has worked 40 quarters. Part B is available and covers outpatient hospital, doctors, etc.”

People who use the Part B plan have to pay premiums. However, they can opt out during their enrollment period.

“They (might opt out) because they have coverage through work or don’t need to or want Part B,” she says. “More and more boomers are not ready to retire at age 65. You do not have to be retired to use Medicare and can continue to work. If you decide that you no longer want the company plan or are retiring, you would apply for Medicare A and B. “

Medicare can possibly cost less than the company plan. She says people should research the difference between plans.

Also, don’t forget prescriptions.