As Medicare celebrates its 50th anniversary this year, I’m grateful it has been there to help my grandparents, parents and sister. We couldn’t have coped without it.
Even so, Medicare can be complicated for a caregiver to understand and manage. Other caregivers often tell me their biggest challenge in managing a loved one’s finances is dealing with health insurance, including Medicare and Medicaid.
For example, when my parents’ primary care doctor of more than 20 years decided not to accept their new Medicare Advantage plan, it put me into a tailspin — trying to understand the new policy, find a new doctor and manage their claims. I thought I knew a lot about Medicare coverage, but I quickly learned there is always more to learn.
Trying to understand all the details can be overwhelming, but I’ve found many good resources and experts available to help me deal with specifics. Below, I’ve provided a quick lesson in the basics, as well as some of the most important issues caregivers need to understand.
What is Medicare?
- Medicare is available for people age 65 or older, adults younger than 65 who have disabilities, and people in end-stage renal disease.
- Medicare Part A is hospital insurance but includes skilled nursing, hospice and some aspects of home health care. Part B is medical insurance (doctor visits, other aspects of home health care, tests, shots, ambulance, etc.). Part D is prescription drug insurance. Medicare Advantage plans are sometimes called Part C and are run by private insurance companies.
What/how do my loved ones pay for Medicare?
- Medicare has monthly premiums, deductibles and copays.
- Premiums for Part B are automatically deducted from Social Security, Railroad Retirement Board (RRB) or civil service benefits. A person who doesn’t have these benefits and elects to receive Part B will get a monthly bill.
- There are savings programs that may help pay for premiums. Contact your State Health Insurance Program (SHIP) or your Social Security office for help with questions and applications.
- Medicare Part D “Extra Help” helps people with limited income/assets pay for prescription drug premiums, deductibles and copays.
What is supplemental or “Medigap” insurance? Medicare doesn’t pay for everything. Medigap supplemental insurance, depending on the policy, can cover most or all of your out-of-pocket expenses (like copays) under the traditional Medicare program. Some people have retiree benefits from a former employer that precludes the need for Medigap, but if you need the extra coverage, Medigap policies are available from a variety of private insurance companies.
Be sure you know what Medicare covers. These are key coverage areas caregivers need to know:
- Skilled home health services: Skilled nursing care and occupational, physical and/or speech therapy at home are covered if your loved one is homebound and a doctor orders these services — but only for a limited time, usually after a hospitalization and only through a Medicare-certified home health agency. Previously, coverage would stop if the patient wasn’t showing “improvement,” but that’s no longer the case — and don’t let services tell you otherwise. A recent court case determined that Medicare coverage could continue if required for “maintenance” of health and skills.
- Personal care and home health aides: If patients qualify for skilled home health services, Medicare will pay for a home health aide to help with personal care (essentially, bathing, dressing and toileting) for the time they are receiving skilled services. But personal care is not covered otherwise and not on an ongoing basis, and Medicare does not pay family members to provide this care.
- Skilled nursing facility: Medicare pays for a nursing facility only when qualifications are met — such as having spent three days as an inpatient in a hospital — and only for a limited time.
- Assisted living or independent living in a senior community: This is not covered by Medicare.
- Hospice care: Medicare pays for in-home hospice care or an inpatient facility.
- Medical supplies and equipment: Medicare pays for certain supplies (such as wound-care supplies, feeding tubes, catheters, oxygen and diabetic supplies) when provided by a Medicare-certified home health agency. It will also pay part of the cost for purchase or rental of wheelchairs, walkers, hospital beds (in some cases) and other medically necessary supplies.
What if I want to appeal a coverage decision? If your loved ones are denied coverage by Medicare, they can appeal — or if you have power of attorney, you can appeal on their behalf. There are time limits for appeals, so be sure to do so right away.
Who can answer my questions? Your best bet is to take advantage of these resources to ask your Medicare questions or better understand situations that might arise:
- SHIP counselors can provide personal help on all Medicare and Medicaid issues free of charge.
- Medicare.gov Caregiving Resources or call 800-MEDICARE (800-633-4227).
- AARP’s Medicare/Medicaid Resources, including the Medicare Q & A from expert and author of Medicare for Dummies, Patricia Barry (aka Ms. Medicare).
- The Center for Medicare Advocacy offers self-help appeals packets and other information.
- The Medicare Rights Center may offer help with legal issues.
Amy Goyer is AARP’s family, caregiving and multigenerational issues expert; she spends most of her time in Phoenix, where she is caring for her dad, who lives with her. She is the author of AARP’s Juggling Life, Work and Caregiving. Follow Amy on Twitter @amygoyer and on Facebook .