Medicare - Health Insurance
Types:
Who Qualifies?
Part A – Hospital Insurance
Part B – Supplemental Medical Insurance
Part C- Combines Part A & B through a HMO or PPO
Part D – Prescription Drug Benefit
Medicare Part A (Hospital Insurance) helps covers your inpatient care in hospitals. Part A also helps cover skilled nursing facility, hospice, and home health care if you meet certain conditions.
Skilled Nursing Facility Care
Semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies (only after a 3-day minimum inpatient hospital stay for a related illness or injury) for up to 100 days in a benefit period. To get care in a skilled nursing facility, you must need skilled care like intravenous injections or physical therapy. Medicare does not cover long-term care or custodial care in this setting. See more specific information below.
Medicare Part B (Medical Insurance) helps cover medically necessary services like doctors’ services and outpatient care. Part B also helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse.
Medicare Part C (Medicare Advantage Plans) is another way to get your Medicare benefits. It combines Part A, Part B, and, sometimes, Part D (prescription drug) coverage. Private insurance companies approved by Medicare manage Medicare Advantage Plans. These plans must cover medically necessary services. However, plans can charge different co-payments, coinsurance, or deductibles for these services. You must go to a physician that is in the network. Must be enrolled in Part A and Part B and pay Part B premiums. You cannot buy Medicare Supplements.
Types of Plans
1) Health Maintenance Organization Plan HMO -
2) Preferred Provider Organization Plan (PPO)
3) Private Fee-for-Service Plan (PFFS). – Some offer Drug Plan
4) Medical Savings Account Plan (MSA) – do not offer Drug Plan, health plan and bank account – Medicare gives money to plan to put in bank account, money is used towards deductible after money is gone, then plan pays your bills.
5) Special Needs Plans (SNP). – do offer Drug Plan, plan is open to:
a) live in certain institutions (like a nursing home) or who require nursing care at home
b) are eligible for both Medicare and Medicaid
c) have one or more specific chronic or disabling conditions (like diabetes, congestive heart failure, mental illness, or HIV/AIDS).
Medicare Part D (Medicare Prescription Drug Coverage) helps cover prescription drugs. This coverage may help lower your prescription drug costs and help protect against higher costs in the future. Can be through Original Medicare or through the Advantage Plan. Pay additional premium to private insurance company.
Most Medicare drug plans have a coverage gap. This means that after you and your plan have spent a certain amount of money (varies by plan) for covered drugs, you have to pay all costs out-of-pocket for your drugs while you are in the “gap.” Once you reached the plan amount, you are considered “catastrophic” and only pay co-payment or coinsurance.
Appeal Process
Services
Advance Beneficiary Notice (ABN): - This notice says Medicare will not pay some Medicare services in certain situations. You will be asked to sign an agreement that says you will pay for the service you want to get if Medicare does not pay for it.
How to Appeal
1) Get the Medicare Summary Notice (MSN) that shows the item or service you are appealing.
2) Circle the item(s) on the MSN you disagree with and write an explanation on the MSN of why you disagree.
3) Sign and write your telephone number on the MSN.
4) Send the MSN and any additional information to address in the “Appeals Information” section of the MSN.
5) file the appeal within 120 days of the date you get the MSN.
Drugs
Ask your drug plan for an exception if:
1) you or your doctor believe you need a drug that is not on your drug plan’s list of covered drugs.
2) you or your doctor believe that a coverage rule (such as prior authorization) should be waived.
3) you think you should pay less for a non-preferred drug because you or your doctor believe you cannot take any of the preferred drugs for the same condition.
How to Appeal
1) 60 calendar days from the date of the drug plan’s decision to request an appeal.
2) must be made in writing, unless your Medicare drug plan accepts requests by phone.
3) can request expedited – decision in 72 hours (7 days for a standard request)
Medigap and Medicare Supplements Insurance
A Medigap policy: - does not fill in the gap of Medicare and does not pay for all areas that Medicare did not pay for.
Facts:
Q. Does Medicare pay for a nursing home stay?
A. In most cases it will not. Medicare is a Federal health insurance program for people who are age 65 or older, some people with disabilities under age 65, and people with End-Stage Renal Disease or people with Lou Gehrig’s disease.
However, Medicare will cover the first 100 days of care in a nursing home if: 1) you have a qualifying hospital stay of 3 full days; 2) you were admitted in the hospital and not listed as observed in the hospital 3) you are receiving skilled care and are still getting better. There are also some deductibles and co-pays. The first 20 days are covered by Medicare and day 21 to day 100 there is a co-pay of $194.50 per day (2022). Medicare also covers limited home visits for skilled care.
Medicaid/Title 19
Q. What is Medicaid/Title 19?
A. Medicaid covers long term care services and might cover you if you meet your state’s poverty criteria and receive care that meets your state’s guidelines. Medicaid is a state/federal program that provides health coverage for Wisconsin residents that are elderly, blind, or disabled (EBD) and is based on your assets and income. You may receive Medicaid even while you are on Medicare. Medicaid will pay deductibles and coinsurance
Q. How do I qualify for Medicaid?
A. You must qualify both financially (assets and income) and medically. It is different for a single person and a married couple. The current assets and income allowance in Wisconsin for 2021 for a nursing home are:
Single Person/Widow
•$2000 – Allowable Assets
•$1500 – Life Insurance
•Unlimited Value – Automobile
•Personal Possessions/Wedding rings
•Funeral Trust- Up to $15,000
•Family “Estate Trust” (Irrevocable) if completed 60 months in advance(up to $100,000)
Income - $45.00 per month
Married Couple
Confined Spouse
•$ 2000 – Confine Spouse
•Plus Irrevocable Burial Trust-up to $15,000
Income - $45.00 per month
Community Spouse
•$50,000 – $137,400 – Liquid Assets
•Unlimited Value – Automobile
•IRA, 401K, Qualified Plans Exempt
•$1500 – life insurance
•Irrevocable Funeral Trust - $15,000 each spouse
•Home – Exempt - $750,000
•Family “Estate Trust” (Irrevocable)
Income - up to $ 3,435.00 (2021) or $2,903.34 plus an excess shelter allowance for spouse
For more information on assets and income click here.
Q. What is a divestment?
A. When you transfer any asset or resources that you own and do not receive fair market value for that asset or resource. You may not give away any asset or resources that you own 5 years before you apply for Medicaid otherwise a divestment will occur and there will be a penalty period. A divestment penalty period is a period of time when Medicaid EBD will not pay for nursing home care or long term care benefits through the Community Waivers Program, Pace, Partnership, or Family Care. Persons may still be able to get limited Medicaid EBD card services during the divestment penalty period.
Q. What is an Irrevocable Funeral Trust?
A. An Irrevocable Funeral Trust is an insurance product that will protect funds which will be solely used for your funeral expenses. An Irrevocable Funeral Trust may be purchased for yourself, your spouse, your children and your children's spouses. This will not be counted as an asset nor will it be considered a divestment when applying for Medicaid purposes. You may not cash the policy in or change the beneficiary because it is irrevocable.
What expenses are paid for by an Irrevocable Funeral Trust?
A. Basic Services of Funeral Director & Staff Professional Services Embalming and anything that the funeral director will allow to be billed for including but not limited to: Dressing / Cosmetology Casketing, Funeral Home Facilities and/or Staff Services, Viewing/Visitation, Funeral Service, Memorial Service, Graveside Service, Clergy Honorarium, Death Certificates, Musicians, Temporary Marker, Stationery Package, Obituary Notices, Flowers, Clothing, Open/Close Casket, Alternative Container, Outer Burial Container, Transportation Equipment & Driver, Transfer of Deceased Funeral Vehicle/Hearse, Car/Limousine, Utility/Service Vehicle, and Cemetery Charges
Q. What is an Estate Trust?
A. An Estate Trust is an insurance product that will protect funds for your beneficiaries if you need Medicaid; however, it must be done at least 5 years in advance of apply for Title 19.
Q. What changes were made in August 2014 by Act 20?
A. These are a few of the changes made:
Information Concerning Long Term Care Insurance
The following information is provided by US Department of Health and Human Services:
The need for long-term care services is expected to increase dramatically in this country as the population ages. Changing demographics, along with other factors may reduce the ability of family members to take care of elderly relatives placing additional demands on public and private programs.
Long Term Care services can be provided in: Own home
Policy should contain:
Policy will pay benefits if you need 3 out of the 6:
Medicare - Health Insurance
Types:
- Original Medicare Plan – Part A and Part B
- Medicare Advantage Plan – Part C
Who Qualifies?
- People 65 and older
- People who has end-stage renal disease requiring dialysis or kidney transplant
- Disabled individual who have received disability benefits for two years form SS and under 65
Part A – Hospital Insurance
Part B – Supplemental Medical Insurance
Part C- Combines Part A & B through a HMO or PPO
Part D – Prescription Drug Benefit
Medicare Part A (Hospital Insurance) helps covers your inpatient care in hospitals. Part A also helps cover skilled nursing facility, hospice, and home health care if you meet certain conditions.
Skilled Nursing Facility Care
Semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies (only after a 3-day minimum inpatient hospital stay for a related illness or injury) for up to 100 days in a benefit period. To get care in a skilled nursing facility, you must need skilled care like intravenous injections or physical therapy. Medicare does not cover long-term care or custodial care in this setting. See more specific information below.
Medicare Part B (Medical Insurance) helps cover medically necessary services like doctors’ services and outpatient care. Part B also helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse.
Medicare Part C (Medicare Advantage Plans) is another way to get your Medicare benefits. It combines Part A, Part B, and, sometimes, Part D (prescription drug) coverage. Private insurance companies approved by Medicare manage Medicare Advantage Plans. These plans must cover medically necessary services. However, plans can charge different co-payments, coinsurance, or deductibles for these services. You must go to a physician that is in the network. Must be enrolled in Part A and Part B and pay Part B premiums. You cannot buy Medicare Supplements.
Types of Plans
1) Health Maintenance Organization Plan HMO -
2) Preferred Provider Organization Plan (PPO)
3) Private Fee-for-Service Plan (PFFS). – Some offer Drug Plan
4) Medical Savings Account Plan (MSA) – do not offer Drug Plan, health plan and bank account – Medicare gives money to plan to put in bank account, money is used towards deductible after money is gone, then plan pays your bills.
5) Special Needs Plans (SNP). – do offer Drug Plan, plan is open to:
a) live in certain institutions (like a nursing home) or who require nursing care at home
b) are eligible for both Medicare and Medicaid
c) have one or more specific chronic or disabling conditions (like diabetes, congestive heart failure, mental illness, or HIV/AIDS).
Medicare Part D (Medicare Prescription Drug Coverage) helps cover prescription drugs. This coverage may help lower your prescription drug costs and help protect against higher costs in the future. Can be through Original Medicare or through the Advantage Plan. Pay additional premium to private insurance company.
Most Medicare drug plans have a coverage gap. This means that after you and your plan have spent a certain amount of money (varies by plan) for covered drugs, you have to pay all costs out-of-pocket for your drugs while you are in the “gap.” Once you reached the plan amount, you are considered “catastrophic” and only pay co-payment or coinsurance.
Appeal Process
Services
Advance Beneficiary Notice (ABN): - This notice says Medicare will not pay some Medicare services in certain situations. You will be asked to sign an agreement that says you will pay for the service you want to get if Medicare does not pay for it.
How to Appeal
1) Get the Medicare Summary Notice (MSN) that shows the item or service you are appealing.
2) Circle the item(s) on the MSN you disagree with and write an explanation on the MSN of why you disagree.
3) Sign and write your telephone number on the MSN.
4) Send the MSN and any additional information to address in the “Appeals Information” section of the MSN.
5) file the appeal within 120 days of the date you get the MSN.
Drugs
Ask your drug plan for an exception if:
1) you or your doctor believe you need a drug that is not on your drug plan’s list of covered drugs.
2) you or your doctor believe that a coverage rule (such as prior authorization) should be waived.
3) you think you should pay less for a non-preferred drug because you or your doctor believe you cannot take any of the preferred drugs for the same condition.
How to Appeal
1) 60 calendar days from the date of the drug plan’s decision to request an appeal.
2) must be made in writing, unless your Medicare drug plan accepts requests by phone.
3) can request expedited – decision in 72 hours (7 days for a standard request)
Medigap and Medicare Supplements Insurance
A Medigap policy: - does not fill in the gap of Medicare and does not pay for all areas that Medicare did not pay for.
Facts:
- Pays coinsurance and deductibles.
- only covers one person.
- policy must offer the same basic benefits, no matter which insurance company sells it. 12 policies nationwide (A-L) Wisconsin only has one
- difference is the cost.
- Medigap policies that are currently being sold can’t include prescription drug coverage unless purchased before 1/1/2006
- Do not cover long-term care (like care in a nursing home), vision or dental care, hearing aids, eyeglasses, and private-duty nursing.
- policy is guaranteed renewable.
- Not the same as Medicare Select policies (HMO and PPO)
- No Health Information if you enroll within 6 months of enrolling in Part B
- Medigap policies can be priced or “rated” in 3 ways:
- a) Community-rated (also called “no-age-rated”) – everyone pays the same no matter how old you are
- b) Issue-age-rated – based on age you buy
- c) Attained-age-rated – based on age you are – goes up as your age does
Q. Does Medicare pay for a nursing home stay?
A. In most cases it will not. Medicare is a Federal health insurance program for people who are age 65 or older, some people with disabilities under age 65, and people with End-Stage Renal Disease or people with Lou Gehrig’s disease.
However, Medicare will cover the first 100 days of care in a nursing home if: 1) you have a qualifying hospital stay of 3 full days; 2) you were admitted in the hospital and not listed as observed in the hospital 3) you are receiving skilled care and are still getting better. There are also some deductibles and co-pays. The first 20 days are covered by Medicare and day 21 to day 100 there is a co-pay of $194.50 per day (2022). Medicare also covers limited home visits for skilled care.
Medicaid/Title 19
Q. What is Medicaid/Title 19?
A. Medicaid covers long term care services and might cover you if you meet your state’s poverty criteria and receive care that meets your state’s guidelines. Medicaid is a state/federal program that provides health coverage for Wisconsin residents that are elderly, blind, or disabled (EBD) and is based on your assets and income. You may receive Medicaid even while you are on Medicare. Medicaid will pay deductibles and coinsurance
Q. How do I qualify for Medicaid?
A. You must qualify both financially (assets and income) and medically. It is different for a single person and a married couple. The current assets and income allowance in Wisconsin for 2021 for a nursing home are:
Single Person/Widow
•$2000 – Allowable Assets
•$1500 – Life Insurance
•Unlimited Value – Automobile
•Personal Possessions/Wedding rings
•Funeral Trust- Up to $15,000
•Family “Estate Trust” (Irrevocable) if completed 60 months in advance(up to $100,000)
Income - $45.00 per month
Married Couple
Confined Spouse
•$ 2000 – Confine Spouse
•Plus Irrevocable Burial Trust-up to $15,000
Income - $45.00 per month
Community Spouse
•$50,000 – $137,400 – Liquid Assets
•Unlimited Value – Automobile
•IRA, 401K, Qualified Plans Exempt
•$1500 – life insurance
•Irrevocable Funeral Trust - $15,000 each spouse
•Home – Exempt - $750,000
•Family “Estate Trust” (Irrevocable)
Income - up to $ 3,435.00 (2021) or $2,903.34 plus an excess shelter allowance for spouse
For more information on assets and income click here.
Q. What is a divestment?
A. When you transfer any asset or resources that you own and do not receive fair market value for that asset or resource. You may not give away any asset or resources that you own 5 years before you apply for Medicaid otherwise a divestment will occur and there will be a penalty period. A divestment penalty period is a period of time when Medicaid EBD will not pay for nursing home care or long term care benefits through the Community Waivers Program, Pace, Partnership, or Family Care. Persons may still be able to get limited Medicaid EBD card services during the divestment penalty period.
Q. What is an Irrevocable Funeral Trust?
A. An Irrevocable Funeral Trust is an insurance product that will protect funds which will be solely used for your funeral expenses. An Irrevocable Funeral Trust may be purchased for yourself, your spouse, your children and your children's spouses. This will not be counted as an asset nor will it be considered a divestment when applying for Medicaid purposes. You may not cash the policy in or change the beneficiary because it is irrevocable.
- Ownership is assigned to Funeral Trust that is provided by Insurance Company at no cost
- Funds avoid probate and delays, pays directly to ANY Funeral Home that the family may choose
- Medicaid exempt in most states
- Excess funds sent to estate of insured but may be recovered for benefits received under Medicaid
- Guaranteed Issue, no medical exams
- Simple application, Issue ages 0-99
- 1035 Exchanges Accepted (transfer Cash Value from older Life policies that are not Medicaid exempt)
- Amounts from $500 up to $15,000 per insured (Single or Multi-Pay options)
What expenses are paid for by an Irrevocable Funeral Trust?
A. Basic Services of Funeral Director & Staff Professional Services Embalming and anything that the funeral director will allow to be billed for including but not limited to: Dressing / Cosmetology Casketing, Funeral Home Facilities and/or Staff Services, Viewing/Visitation, Funeral Service, Memorial Service, Graveside Service, Clergy Honorarium, Death Certificates, Musicians, Temporary Marker, Stationery Package, Obituary Notices, Flowers, Clothing, Open/Close Casket, Alternative Container, Outer Burial Container, Transportation Equipment & Driver, Transfer of Deceased Funeral Vehicle/Hearse, Car/Limousine, Utility/Service Vehicle, and Cemetery Charges
Q. What is an Estate Trust?
A. An Estate Trust is an insurance product that will protect funds for your beneficiaries if you need Medicaid; however, it must be done at least 5 years in advance of apply for Title 19.
- The Estate trust is a great way to pass assets to beneficiaries and charities (Church, schools, animal shelter, Red Cross, Salvation Army, etc.)
- Income Tax Free to Beneficiaries
- Medicaid Exempt after 60 months
(unlike other investments and bank accounts, unless in an Irrevocable Trust) - Money set aside is Irrevocable, and beneficiary cannot be changed.
Q. What changes were made in August 2014 by Act 20?
A. These are a few of the changes made:
- Prevents the spouse at home, from transferring the community spouse’s assets to anyone else until the institutionalized spouse has been on Medicaid for five years!
- If the community spouse transfers assets in the first five years after an institutionalized spouse is receiving Medicaid, then the institutionalized spouse might lose eligibility for Medicaid.
- Non-Probate Assets that would typically transfer to family members are now subject to estate recovery- Annuities, Life Insurance, POD and TOD accounts, Living Trusts or any Financial Investment (unless in an
Irrevocable Trust or Funeral Trust) - Life Estate is no longer 100% non-countable assets after 5 years.
Information Concerning Long Term Care Insurance
The following information is provided by US Department of Health and Human Services:
The need for long-term care services is expected to increase dramatically in this country as the population ages. Changing demographics, along with other factors may reduce the ability of family members to take care of elderly relatives placing additional demands on public and private programs.
- In 2011, 77 million people will turn 65, and by 2025, the number of Medicare beneficiaries is expected to reach 69.3 million, representing 20.6 percent of the U.S. population.
- Over the same period, those over age 80 will comprise the fastest growing segment of the population.
- Four out of every 10 people turning age 65 will use a nursing home at some point in their lives, and many will need home care and other related services as well.
- By 2020, 12 million older Americans will need long term care.
- Women are almost three times more likely to live in a nursing home than men.
Long Term Care services can be provided in: Own home
- Assisted living facilities
- Nursing homes
- Adult day care centers
- Hospice facilities
Policy should contain:
- No hospital stay before receiving benefits
- Renew always with paid premiums
- Stop paying premiums when you receive benefits
- One deductible per life of policy
- Covers preexisting conditions
- 5% compound interest over life of policy
- Allows for downgrading of policy
- Coverage for dementia
- Clearly explains eligibility
- Written by a reputable insurance company
Policy will pay benefits if you need 3 out of the 6:
- Transferring – bed, wheelchair etc.
- Toileting –onto, off, to and from
- Bathing – including sponge bath
- Dressing – including braces, fasteners and artificial limb
- Eating – feeding from plate, cup or table or feeding tub
- Continence – control bladder and personal hygiene
