Medicare 2014

As in years past, Medicare will be implementing changes to the program for 2014.  Below I compare the Medicare benefits in 2014 to the Medicare benefits from 2013.  Be aware that Medicare is neither associated with nor part of the Affordable Care Act (ACA, ObamaCare), and that these annual changes are in keeping with Medicare changes in the past.  Also be aware that the figures outlined below represent Medicare only: These numbers do not account for the Medicare Supplement or Medicare Advantage plans that most people have to supplement their Medicare coverage.

Part A                                                       2013                2014          

Hospitalization

Days 1-60 Co-Insurance                       $1,148.00         $1,216.00

Days 61-90 Daily Co-Pay                          296.00             304.00

Days 91-120 (One time only days)*          592.00             608.00

Skilled Nursing Care

Days 1-20                                                     100%              100%

Days 21-100 Daily Co-Pay**                     148.00             152.00

Days 101+                                        No Coverage    No Coverage

Part B                                                                                              

Annual Deductible                                    $147.00           $147.00

Physician Visits Co-Pay                                 20%                20%

Out Patient Labs                                           20%                20%

Out Patient Procedures                                  20%                20%

Medical Equipment                                        20%                20%

There are two types of plans to supplement Medicare; Medicare Advantage and Medicare Supplements.  Medicare Advantage plans are similar to HMO's and PPO's.  There are typically preferred and/or network providers who have contracted with the plan to provide services at an agreed price.  These plans are typically regional plans and often include co-pays and co-insurance payments from the patient.  While the Center for Medicare and Medicaid Services (CMS) requires these plans to be "actuarially equivalent" to Medicare, the variations are far too numerous to list here.  Before considering a Medicare Advantage plan, review the co-pays and co-insurance payments required.  Medicare Advantage plans are typically less expensive than Medicare Supplements.  

Medicare Supplement plans are accepted nation wide by any provider who accepts Medicare.  Though many companies offer Medicare Supplements, each plan is regulated by CMS, and each plan of the same type offers exactly the same coverage no matter what company issued the plan.  These plans tend to be a little more expensive but often times involve fewer or lower co-pays.  While Medicare Advantage plans do not require a medical review, Medicare Supplements often do. 

When first becoming eligible for Medicare parts A and B, it is important to understand your choices and options.  Some decisions can not be changed once you make your initial selection, so it is wise to employ the help of an Elder Care Consultant or a Licensed Insurance Agent in order to appropriately plan for your care both today and in the future.

* Medicare includes these days as a life time benefit.  When they are used once, they are no longer available and the patient is responsible for 100% of medical costs.  Many Medicare Advantage and Medicare Supplement plans provide up to 365 additional days of this benefit.

** Medicare pays 100% for days 1-20 provided the care is deemed to be medically necessary.  Medicare Advantage and Medicare Supplement plans may have different requirements to qualify medical necessity.  In my experience it is rare to see anyone receive 100 medically necessary days in a skilled nursing facility.  It is also important to remember that once care is no longer medically necessary and insurance is no longer paying for care, the patient is responsible for 100% of the nursing care costs.

Senior Citizens, the Debt Ceiling, and the National Budget.

As our elected officials continue to struggle with the government shut down, a bigger demon is lurking behind them, and behind us.  While essential services continue during the government shut down (though some delays may occur in benefits as time increases), a failure to have funds to pay the nations bills could have a more profound effect on these essential services.

Technically speaking a default will occur when the government can not, or does not, make regular payments to bond holders for borrowed money.  But even if these payments are made there can be catastrophic consequences in terms of benefit payments, availability of services, and both the national and world economies.  It appears there will be enough money to make interest payments to bondholders for November but there will not be enough money to pay those bills and to make payments for social programs, like Social Security and Medicare, and to pay soldiers, civilian staff, and other liabilities. 

What order will other bills be paid?  Unfortunately it is not a simple question and is indeed new territory for our nation.  The decision will not be as clearly defined as it is for the shut down.  Strategies have been introduced to suggest a method to prioritize payments but each has problems and none has been widely accepted as feasible.  During the shut down, funds are available in the budget for all programs.  If a debt ceiling solution is not reached then money simply will not be available and the government will not be authorized to borrow more.  The government, in effect, will be living pay check to pay check incurring more bills than it is able to pay.

The Treasury Secretary is scheduled to address the debt ceiling and the prioritization of bills when he testifies in front of the Senate on Thursday, which has been dubbed by some press organizations as "prioritization day".

The Treasury Department maintains that even if some prioritization agreement could be reached it is not technically feasible to implement.  Government computer systems are programmed to automatically make payments as they come due.  With millions of checks issued each day and with aging technology, choosing which bills to pay and which to hold just isn't possible.  If there is not enough money to pay the bills, all checks would continue to be printed and mailed but some will bounce.  It might be a Social Security check, a pay check, or an interest payment.  There is one way the Treasury could have some control over what is paid. The Bureau of the Public Debt could make payments to bond holders while the automated system for paying bills is simply turned off, however, this does not address how any other payments will be made.

There are legal issues as well.  There is no legal order for the payments to be made.  It is unclear if the Treasury has the legal ability to make those decisions.  Does Congress need to approve each payment?  Can the President decide without input Congress or the Treasury?  There are just no clear answers.

The most likely scenario is that the Treasury will turn off the automated payment system and will pay bills as they accumulate enough cash to make all of a given days payments.  For example, the payments due to be paid on November 1, 2013 (including Social Security) will be paid when the Treasury has enough cash to cover all of the payments due on November 1.  That might be on November 2, or 4, or 10, or 30.  The automated system will make payments as they come due, as it is designed, and will be switched off again until enough cash is available to make the payments due the next day.  This solution allows the Treasury system to function without significant adjustments and also removes the responsibility of deciding what to pay for.  No services will be cut but payments for all programs will be delayed.

It is important to remember that borrowed money accounts for about one third of the money spent each month.  Money will continue in to the government every month even if a debt ceiling agreement is not reached, but those funds will not be sufficient to pay everything.  While there may be a delay in payments for a few days for November 1, 2013, payments due November 30, 2013 may be delayed by a week, a month, or more.

While I can not provide specific answers regarding social programs and the debt ceiling, I can caution you to be aware of the possibilities and to have a back up plan in place. 

Government Shut Down and the Elderly

No matter which side of the aisle you're on or who you want to blame for the government shut down, we find ourselves dealing with the consequences.  "Essential" services will continue while "non-essential" services will be suspended.  What does that mean for us and our loved ones? I have identified many government programs that our seniors depend on and noted the status of each during the shut down.

These programs will continue to be operational during the government shut down:

• US Mail - Should continue without any interruptions
• Food safety inspections - Should continue without any interruptions
• Social Security Checks - Should continue without any interruptions
• Food Stamps - Should continue without interruptions
• CDC - Will continue to operate though there will be significant limitations, see below
• Medicare - Will continue to operate with some limitations, see below
• VA - Will continue to operate with limitations, see below
• Medicaid - Should continue without interruptions

These programs will not operate or will operate with limited services during the shut down:

• Social Security Applications - New applications for benefits may not be processed
• Social Security Appeals - Will not be processed
• Social Security Replacement Card Requests - Will not be processed
• Social Security Benefit Verification Statement Requests - Will not be processed
• Social Security Earnings Record Requests - Will not be processed
• Social Security Appeals for Denial of Benefits - Will not be processed
• Medicare Applications - New applications for benefits may not be processed
• Medicare Appeals for Denial of Benefits - Will not be processed
• VA Appeals for Denial of Benefits - Will not be processed
• CDC Ability to Investigate - CDC will have extremely limited resources to investigate reports of outbreaks and other serious health concerns
• CDC Assistance to State and Local Governments - Will be unavailable
• CDC Annual Influenza Program - (Tracks the flu and helps people get shots) Will be closed

If you or a loved one depends on these or other programs that depend on federal funding, begin making contingency plans now.  The shut down may last hours or it may last weeks, but when these offices resume "normal" operations it will take time for them to catch up with work that accumulated during the shut down.

If you or a loved one experiences significant difficulties because of an unavailable service a qualified Elder Care Consultant or Geriatric Care Manager may be able to help you make suitable arrangements until services resume.

Flu Shots for Care Givers: Necessary?

The short answer is yes.  I see the eyes rolling. I see your mouth forming the words "...and I always get sick after I get the shot!" I hear "I've never had one before, I'm not starting now!" and "I'm healthy and never get the flu, I don't need one." and (in your best martyr voice) "It's more important for at risk people to get the shot first so I'll wait!."  If you can personally identify with any of these, let me explain why you need to change your position on the flu shot. Let's start with some facts.

• Every year the strain(s) of flu viruses change.  The shot you had last year (or 5 years ago) most likely will not be effective this year.
• More than 50% of hospitalizations for flu are people aged 65 or older.
• 90% of flu related deaths are people aged 65 and older.
• The flu is contagious about 24 hours before there are symptoms.
• The flu shot does not contain any live or active virus of any kind. Though you may have had an illness after getting a flu shot it is not possible to get ill from the shot, short of having an allergic reaction, which can happen in a small percentage of people.

"But" I hear you say "I'm not that old!"  

In Pennsylvania, and I'm sure across most of the nation, emphasis is not only to vaccinate those we serve but to vaccinated ourselves. Experience has taught us that if we keep the flu out of our homes and out of our facilities, we can greatly reduce the incidence of the flu in those we serve.  In my own facilities and in two other facilities I have run, when we get more than 90% of the caregivers vaccinated we have gone some years without even one flu related hospitalization. Increasingly, health care facilities are taking a strong stand on the flu shot, requiring caregivers to either get the shot or to wear a mask while working, recognizing that reducing the risk of transmission is the most effective tool to protect our seniors.

Many of those we serve rarely get out into the community.  So where do they get the flu? From us. Remember that you are contagious before you begin to get symptoms. Remember that just because your immune system is able to effectively fight off the virus, you are still very capable of spreading it to others you interact with.

Managers - you need to set the example for your staff.  If you don't take the issue seriously your staff won't either.

Care givers - Family and friends providing care in someone's home, home health workers, nurses aides, nurses, therapists, environmental service staff, dietary staff, activities staff, and any other worker who has regular contact with our seniors - you have daily contact with those you care for and pose the greatest risk of spreading the flu. Your residents are counting on you to help them stay healthy.

Employers - Looking for a way to reduce resident/patient hospitalizations? Need to get employee sick time under better control? Find your agency staff usage skyrocketing during the flu season? Provide the flu shot to you staff free of charge, it is inexpensive insurance against increased resident care costs and staffing costs.

Having opened your mind and having carefully considered the information above I'm sure you now agree that getting the flu shot this year is a great way to keep your residents/patients healthier this flu season. 

Laughter

Laughter is in fact good medicine.  It is also a good coping mechanism to help you get through a stressful situation.  Other times we need a distraction for a few moments to clear our minds.  In light of these I bring you the following which might fit both bills.

• Why is it a package transported by ship is cargo while a package transported by car is a shipment?
• If con is the opposite of pro, is congress the opposite of progress?
• Why do we put garments is a suitcase and suits in a garment bag?
• Why do tug boats push?
• Why do we call the benches at the ball park stands when they are made for sitting?
• Why do we call them apartments when they are stuck together?
• Why is phonics not spelled the way is sounds?
• Why is abbreviation such a long word?
• Who was the cruel person who put an "S" in the word lisp?
• Why does the word "monosyllabic" have 5 syllables?
• How can there be interstate highways in Hawaii?
• We know the speed of light is 299,792,458 meters per second.  What is the speed of dark?
• If it is 0 degrees outside today and it is supposed to be twice as cold tomorrow, how cold will it be?
• Why are there Braille dots on drive up ATM's?
• Why does your nose run and your feet smell?
• Why do we call it a building if it is already built?
• If corn oil comes from corn, olive oil comes from olives, and vegetable oil comes from vegetables, what is baby oil made from?
• If crime fighters fight crime and fire fighters fight fires, what do freedom fighters fight?
• Is there another word for thesaurus?  
• Is there another word for synonym?
• How can there be self help groups?
• If you ask the librarian where to find the self help books should she tell you or would that defeat the purpose?
• If a turtle loses its shell, is it naked or homeless?
• If you try to fail and succeed, which have you done?
• What should you do if you see an endangered animal eating an endangered plant?
• At the movie theater, which arm rest is yours?
• How far east must you travel before you are traveling west?
• Why is it that everyone driving faster than you is an idiot and everyone driving slower than you is a moron?
• What is the difference between regular ketchup and fancy ketchup?
• When does it stop being party cloudy and becoming partly sunny?
• How can an item be new and improved.  If it is new, what was it improving on?
• Ever notice that lemon scented cleaners have real lemon but lemon flavored drinks have artificial flavors?
• Why does someone believe you when you say there a 4 billion stars in the sky but have to check when you tell them the paint is wet?
• Why do we have to click the start button to turn off the computer?
• Why are boxing rings square?
• Why does one recite at a play but play at a recital? 
• If superman can dodge a speeding bullet, why does he need to duck when someone swings a chair at him?
• Why do people who know the least know it the loudest?
• Where do homeless people have 90% of their accidents?
• If white wine goes with fish, do white grapes go with sushi?
• How is it that we put men on the moon before we figured wheels on luggage is a good idea?
• Is atheism a non-prophet organization?
• What if there were no hypothetical situations?
• Is it possible to have a civil war?
• Light travels faster than sound.  Is that why some people appear intelligent until you hear them speak?
• We were taught that the universe includes everything.  Scientists are claiming the universe is expanding.  What is it expanding into.
• I before E except after C...except the word science...
• Why is it called re-search when we are looking for something new?
• Why do we wait until a pig is dead before we cure it?
• If quitters never win, and winners never quit, who was the fool who said quit while you're ahead?
• What ever happened to preparations A through G?
• Who is General Failure and why is he trying to read my hard disk?
• What if the Hokey Pokey IS what it's all about?
• Why are wrong number never busy?

Have a great weekend!

Medicare and Obamacare

Will Obamacare have an effect on Medicare?  There is considerable confusion over the topic not only among those eligible for the benefit but also among social workers and other professionals.  Here I will address the most significant issues.

• Enrollment for Obamacare (Affordable Care Act/ACA) begins October 1, 2013 and runs through March 2014.  Open enrollment for Medicare begins October 15, 2013 and ends December 7, 2013.  Do I need to sign up for coverage under ACA?  Medicare beneficiaries do not need to enroll in coverage under the ACA.  In fact, if they are satisfied with their current coverage they need do nothing for that coverage to continue.  
• Will Medicare be ending?  Medicare is not ending and there are no current plans for Medicare to end.
• Will I have to pay the "penalty" if I don;t sign up for coverage?  Medicare is health insurance and meets the requirements for health coverage under the ACA.  There will be no penalty for Medicare beneficiaries.
• Do I need to get Medi Gap or Part D coverage through ACA enrollment?  State  health care exchanges will not be offering Medi Gap or Medicare D coverage.  Those who call looking for that type of coverage will be referred back to Medicare.
• Will my medications cost more under the ACA?  Maybe.  If you are single and make more than $85,000.00 per year or married and together make more than &170,000.00 you might be paying more for Part D coverage.  Any other increases will be program increases not directly associated with the ACA.
• Will I be able to continue seeing the doctors I choose?  Yes.  There are no new limitations to Medicare coverage.
• Will my Medicare premium increase?  Most likely, but this increase is the typical annual increase in Medicare and is not associated with the ACA.

Medicare is reportedly working on a booklet for Medicare beneficiaries to answer these and other questions.  Plans are to have them out to consumers sometime next month.  

If you are not happy with your current Medicare coverage, or if you want to make changes to your coverage, make sure to take advantage of the open enrollment period as you normally would.

Confusion and misunderstandings of this scope provide a very attractive opportunity for health coverage scams.  Be cautious of phone calls, mail, door-to-door sales, and electronic contact.  Though all of these may be employed by legitimate companies marketing their coverage, there is no need for a person on Medicare to take any action as the ACA is implemented.

Caregiver Neglect

What is neglect?  Neglect is the failure to provide necessary services to a care dependent person and can take many forms.  Not providing proper nutrition, failing to give medications, not assisting with daily hygiene, or failing to provide any other needed service.  Neglect is also a form of abuse.  Who can be a victim of neglect?  Any person who is dependent on another person for any care.  Who can perpetrate neglect?  Any caregiver from a family member, to an in home caregiver, to the caregiver in a facility.  We all want to believe that we have made the best choices to get the best care for our loved ones.  Fact is neglect happens.  Even if you implicitly trust the caregivers it is important that you remain vigilant and watch for signs of neglect.  So, what should you look for?  Neglect can cover a lot of ground depending on what services should be provided but there are some general signs to look for, and there are common areas of neglect.  

Let me begin by saying you need to listen to your loved one and you need to watch their behavior.  If they report being uncomfortable with a caregiver, if they say they have not received certain care, if they shy away from touch, or if you see a negative change in behavior, you need to investigate.  Yes, even for the person with dementia, especially if they are uncomfortable around certain people or there are behavior changes.  Dementia does change the way they see the world and their surroundings but the body retains it's ability to sense and react to danger well into the progression of the disease.  Caregivers often don't understand dementia and believe the person will not know the difference.  But they do know, and we have to be open to receiving the signals they give us.  Over more than twenty years in the industry I have observed how the demented person interacts with caregivers.  Every time the resident had a negative reaction to a caregiver there has been a reason.  Not every reason was abuse or neglect, but in every case I could identify a reason.

Other signs to be alert to:

• Weight loss - if getting a weight is not practical, look for clothing that seems too big and changes in the face.
• Dehydration - Look for red, irritated eyes, dry mouth and lips, dry skin, decrease or absence of voiding, and constipation.
• Sores - Bed sores and pressure ulcers.  These always occur in areas that bear weight.  A person in bed not regularly re-positioned may get them on their heels, buttocks, back, and shoulders.  A person spending too much time sitting up without re-positioning may get them on hips, buttocks, and thighs.  They are usually painful and often times smell of infection.  If you suspect a sore but are uncomfortable looking in these areas ask a trusted spouse, family member, nurse or friend.  The sooner it is identified the quicker it can be healed.  It is worth noting here that ulcers developed or present at end of life may never be successfully healed.
• Dirty home, apartment, or room - If part of the services provided is to include cleaning, look to see if it is happening.  Be alert for offensive smells.  Proper attention to cleaning will eliminate persistent smells.  Look at floors, bath rooms, and the kitchen.  These areas are typically the first to show signs.
• Hygiene - In my experience hygiene is a commonly overlooked area with oral hygiene being the most commonly overlooked or skipped service.  Be alert for complaints of mouth or tooth pain.  Monitor hygiene supplies, are they being used?  Are there bodily odors of sweat, urine, or feces?  Is the same towel and wash cloth in the same place for days on end?  Have finger nails been trimmed and cleaned?  Is hair combed and clean?
• Clothing - Do you see your loved one in the same clothing day after day?  Are clothes soiled?  Can you identify the most recent meal by the stains?  Are socks soiled?  Your nose can be an effective tool here as well.
• Lack of medical aids - Are eye glasses on and clean?  Are hearing aids in place and working?  Are braces or special orthotics in place?  Is the walker, cane, or wheel chair within reach?
• Medications - Are there medications missing or do you find they need refilled before they should be?  Have you been notified that medications need refilled on a regular basis?
• Caregiver behavior - Does the caregiver answer questions you ask your loved one?  Does the caregiver get defensive when you ask question about the care they provide?  Is there always an excuse why something was not done, or why something happened?

This is by no means an all inclusive list but it should help to put you in the right mind set.  If a service should be provided do a little investigating to make sure it is.  Show up unannounced at unexpected times.  Is there a used towel and wash cloth when you show up at 8:00 am?  Are there dishes in the sink after meal time?  Is the care giver coming in late or leaving early?  

If your loved one requires care and you are not personally providing it for them, be their eyes and ears.  If there is significant distance between you, many reputable Elder Care Consultants offer monitoring services to help you know what is, and isn't, happening.