JustCare

Category: Medicaid

  • 8.3 million people benefit from both Medicare and Medicaid

    8.3 million people benefit from both Medicare and Medicaid

    Medicaid is a joint federal and state public health insurance program for 70 million vulnerable people in the United States, funded in large part by the federal government and in some part by each state. Today, 8.3 million people benefit from both Medicare and Medicaid, 4.6 million older adults and about 3.7 million people with disabilities. People with Medicare and Medicaid are sometimes called “dual-eligibles.”

    Medicaid covers about 15 percent of people with Medicare. Medicaid is a cost-effective program delivering a broad benefit package to older adults at about 20 percent less cost than private insurance. That said, a June 2015 Kaiser Family Foundation survey shows that Medicaid offers similar access to care as private insurance.

    People with both Medicare and Medicaid have lower incomes and fewer assets than people who do not qualify for Medicaid. More than 85 percent of them have annual incomes below about $16,500. Even if your income or assets put you above the Medicaid eligibility limit, many states have what are called “spend-down” programs that allow you to qualify for Medicaid after you have spent some of your own money for health care. You should know that if you own a home, Medicaid does not count it as an asset. 

    States must provide a minimum set of Medicaid benefits and have flexibility in terms of offering additional benefits. People with Medicare and Medicaid generally have low out-of-pocket costs. Medicaid helps cover Medicare premiums and out-of-pocket costs. And, as or more importantly, Medicaid also pays for some key services that Medicare does not cover, including community-based long-term services and supports, and nursing home care. And, it covers a wide range of behavioral health services.

    About one-third of Medicaid’s budget goes to paying for long-term services and supports. More than half of Medicaid spending on long-term services and supports is for care at home or in the community. The Program for All-inclusive Care for the Elderly or PACE is a  Medicare-Medicaid program. At the same time, Medicaid covers 64 percent of all nursing home residents.

    Click here to find out if you qualify for Medicaid. Many states allow you to apply on online. Click here to apply. And, click here to contact your state for application and renewal information. And, for simple health and retirement advice you can trust, subscribe to our weekly Just Care feed.

  • For-profit PACE programs: Cause for worry?

    For-profit PACE programs: Cause for worry?

    Sarah Varney reports for Kaiser Health News that the for-profit sector will now be providing a program for all-inclusive care for the elderly (PACE). Click here to learn about PACE on Just Care. Until recently run exclusively by non-profit organizations and paid for by Medicare and Medicaid, PACE has provided valuable services. But it has reached only a small fraction of older adults. Are for-profit PACE programs cause for worry or can they reach more adults and deliver as good results as non-profit PACE programs?

    Last year, Congress changed the law governing PACE to permit for-profit companies to run PACE programs. The alleged goal is to reach more people. And, now private equity firms are funding companies to deliver for-profit PACE programs, reaching many more people.

    PACE is intended to help older adults age in place through comprehensive medical and social supports. Medicare and Medicaid pay for the services because they can save money on people in PACE who remain at home, do not need nursing home care and are not as likely to be hospitalized. But, only 40,000 people were enrolled in the program at the beginning of 2016.

    With for-profits in the picture, more people will receive PACE services. And, that could have great value to patients who want to remain at home, as most do, and still be able to socialize and enjoy the services available in their communities. Without PACE, many would remain isolated and homebound, jeopardizing their health and well-being and putting them at increased risk of an early death.

    PACE programs provide key services many older adults would not otherwise be able to afford or access. People may get comprehensive rehabilitation services. They also generally receive critical dental care that Medicare does not pay for outside the PACE setting. Dental care helps prevent infections that can land a person in the hospital. It also helps to ensure good nutrition.

    And, PACE programs also help patients with basic services at home, such as housecleaning and laundering.

    The question remains whether the for-profit sector will deliver the value that non-profit PACE programs have delivered. When for-profit companies began delivering hospice services, the U.S. Office of the Inspector General found that they were treating patients with less costly conditions, avoiding patients who would cost them more money, and they were holding back on services people needed.

    The for-profit programs are paid a flat fee and lose money if PACE enrollees spend too much time in hospital or visit the emergency room frequently. So, for-profit PACE programs may try to avoid patients more likely to use these services, like the for-profit hospice agencies, avoiding patients who would cost them more money. To save money, they may also be more inclined to deliver care through telehealth rather than transporting patients to facilities, failing to recognize the negative health consequences of social isolation and the value of socialization.

    Here’s more from Just Care:

  • PhRMA fights states on drug pricing

    PhRMA fights states on drug pricing

    Drug prices are rising at crazy rates; in 2015, almost one in three brand-name drugs saw a price increase of 20 percent. In response, more than a dozen states are considering legislation that would call the drug companies to account. Of course, PhRMA is fighting states on drug pricing.

    On June 3, 2016, Vermont’s governor signed into a drug transparency law intended to make drug companies justify huge drug price increases. And, since then, the California Assembly’s Health Committee approved a similar drug price transparency bill, which its Senate has passed, intended to make drug companies justify huge drug price increases. That said, Stat reports that the bill has recently been gutted. 

    Now, a ballot initiative in California, Proposition 61, is designed to reduce the cost of drugs for state agencies. This would not only take a toll on drug company profits, it would set the stage for other states to pass similar initiatives. Not surprisingly, PhRMA has already put $70 million into fighting this initiative.

    Proposition 61 would keep California agencies like MediCal, (California’s Medicaid), which covers poor children, from paying any more for a drug than the lowest price paid by the Veterans’ Administration (V.A.). Ohio has a similar initiative, but PhRMA may successfully keep it from being voted on by bringing a lawsuit challenging it.

    California state agencies today spend $4 billion a year on drugs. If Proposition 61 passes, the state could  could save hundreds of millions of dollars. But, some argue that it would be hard to implement.

    Most drug prices, including discounts and rebates, are not transparent. So, it could be hard to know exactly what the V.A. is paying.  That said, the CBO reported ten years ago that the V.A. pays about 42 percent of the retail prices and Medicaid pays about 52 percent.

    California AARP supports Proposition 61 as does the California Nurses Association. But, according to the New York Times, some advocates oppose it for fear that it will lead drug companies to drive up prices at the V.A. and for others even further. It’s not clear whether some or all of these advocates take money from the drug companies and are therefore conflicted.

    As important as it is for states to be taking action on drug pricing, state action is not likely to succeed at reining in drug prices as much as needed. The pharmaceutical industry is too powerful. But, state activity keeps a spotlight on the pharmaceutical industry and that in turn keeps pressure on Congress to act. How long that will take, however, is anyone’s guess.

    Here’s more from Just Care:

     

  • Telehealth on the rise

    Telehealth on the rise

    Telehealth or telemedicine–the provision of care through telephone or digitally, including video visits and online care–originally was designed to meet the needs of patients otherwise unable to access care, such as people living in rural areas. But, telehealth is on the rise, increasingly meeting the needs of people who want to avoid leaving work to travel to the doctor and keep their costs down.

    Now, according to a July 2016 article on the State of Telehealth in the New England Journal of Medicine, a large number of institutions offer virtual doctor’s visits at low cost 24 hours a day. For many, it’s a great alternative to waiting 20 days to get a doctor’s appointment and then spending 2 hours traveling and waiting for a 20 minute visit.

    People are now more interested in using telehealth to treat a variety of chronic conditions. Nearly half the U.S. population has one or more chronic conditions, 140 million people.  And, telehealth is moving from the hospital to the home, where it can meet the care needs of frail older adults and people with disabilities for whom leaving home is difficult. Combined with sensors on the patient and in the home, providers can learn a significant amount about a patient.

    Health systems with integrated care, such as Kaiser Permanente, the Veterans Administration and the Department of Defense, are finding that telehealth can promote health at less cost than in-person care. Kaiser predicts that it will provide more telehealth visits than in-person visits this year. In 2014, the VA provided more than 2 million telehealth visits. The Mayo Clinic says it will serve 200 million people remotely by 2020, including many who do not live in the United States.

    The biggest constraint on telehealth is that most insurers are not yet covering the cost of the services. But, telehealth coverage is on the rise. And, 29 states now require commercial insurers to cover telehealth services in the same ways they cover in-person care. Already, Medicaid covers some telehealth services today in 48 states.

    Medicare is behind on telehealth services, limiting coverage to areas where it is hard to see a doctor, as we reported here on Just Care. And, digital doctor visits present a bit of a challenge for older adults since only 58 percent of them are online. Moreover, state licensing restrictions limit the out-of-state care doctors can provide. But, there is a bill in Congress, the Tele-Med Act of 2015, which would give providers the right to treat Medicare patients in any state.

    According to Bloomberg BNA, the National Business Group on Health (NBGH) projects that, in 2017, 9 out of 10 large employers will offer employees telehealth services. NBGH further predicts that virtually all large employers, 97 percent, will offer telehealth services within four years.

    Large companies still don’t have a good sense of whether telehealth is bringing down their care costs. In fact, just four years ago, only 7 percent of these companies offered telehealth to their employees. But, they now believe it is a valuable benefit that promotes employee satisfaction. It can save people time and money. And, many insurers are now offering the service.

    Telehealth has its limitations. It puts less of a premium on the doctor-patient relationship–what the doctor can learn from looking a patient in the eye and conducting a physical examination as well as the trust that can be built–than in-person care. Continuity of care is easily lost, with fragmented care taking its place. And, lack of integration in the delivery of telehealth care could lead to conflicting treatments and poor outcomes. There are also privacy concerns.

    On the flip side, telehealth can lead to greater equity in the delivery of health care, reducing racial, gender and age disparities and well as disparities in treatment between people in rural areas and people in urban areas.

    Here’s more from Just Care:

  • Beware of Medicare and Medicaid fraud and, if you see it, report it

    Beware of Medicare and Medicaid fraud and, if you see it, report it

    Medicare fraud is prevalent. It wastes billions of dollars and drives up health care costs. It comes in all varieties but generally involves bills to Medicare for services that were never provided. You can help identify and report it to the Office of the Inspector General or Medicare if your doctor or hospital bills reflect services you never received.

    Earlier this year, the Justice Department and the U.S. Department of Health and Human Services announced charges against 243 people, including more than three dozen doctors and nurses, for participating in $712 million in Medicare and Medicaid fraud through inappropriate billings. In some cases, services were unnecessary and in others they were never performed.

    In this instance, fraud schemes involved a range of services, including home care, psychotherapy, physical therapy, durable medical equipment and pharmacy fraud.

    Since the inception of the Health Care Fraud Prevention & Enforcement Action Team (HEAT) in 2007, the Medicare Fraud Strike Force operations have charged more than 2,300 people with falsely billing Medicare for more than $7 billion.

  • 7 questions you should answer before you turn 65

    7 questions you should answer before you turn 65

    Everyone has lots of questions about their health and financial security as they age. Here are seven questions you should answer before you turn 65 with links to simple information to help you decide what to do:

    1.     Do you need to sign up for Medicare?  Medicare provides health insurance for people 65 and over and people with disabilities, regardless of income.  Whether to enroll in Medicare depends on whether you have employer coverage and what kind you have. (If you have employer coverage through your job or your partner’s job, click here to learn more.) If you do need Medicare:

    • Enrollment in Medicare Part A, hospital insurance, and Part B, medical insurance, is generally automatic if you have signed up for Social Security. Part A is free if you or your spouse has paid into Medicare for at least 40 quarters. You pay the Part B premium unless you qualify for Medicaid. You need Medicare Part B if your employer coverage is no longer primary once you turn 65. (To avoid penalties for mistakenly turning down Part B, check with Social Security at 800-772-1213;  you can also contact your local area agency on aging at 800-677-1116.)
    • Understand your supplemental coverage options and how to choose among them. Medicare only covers about half of your health care costs. If you enroll in traditional Medicare (see below), you will want additional coverage, supplemental coverage, to fill gaps and limit your out-of-pocket costs. For an explanation of your options, click here.  If you enroll in a Medicare Advantage plan, you cannot buy insurance to cover your deductibles and copays and other out-of-pocket costs.

    2.   Should you enroll in traditional Medicare or a Medicare Advantage plan? It depends on the kind of coverage that’s important to you and whether you want as much choice of doctors and hospitals as possible. It also depends on how much you are willing and able to pay to get the coverage you need. Most people choose traditional Medicare because of the enormous choice of doctors and hospitals it offers anywhere in the country. (Note: Some insurers are involuntarily enrolling people in their Medicare Advantage plans when they turn 65. Make sure you’re not involuntarily enrolled.)

    3.    Should you sign up for a Medicare Part D prescription drug plan? In most cases, yes, if you need drug coverage. But, you should understand the limits to that coverage and when your drugs will be covered. Here are six tips for keeping your drug costs down.

    4.     What about Medicaid? Medicaid can pick up many of your health care costs that Medicare does not cover, including your Medicare premium, if your income is low.  Whether you qualify for Medicaid might depend on where you live. You can have both Medicare and Medicaid. Here’s how they work together. And, here’s what you need to know about the ways Medicaid can help you.  Even if you don’t qualify for Medicaid, here are five programs that lower your costs if you have Medicare.

    5.     When should you sign up for Social Security benefits (if you have not already done so) and what will your  Social Security benefits be when you retire?  You should understand the benefits and risks of claiming Social Security early.

    6.     Are you prepared if you need long-term services and supports? Today, two in five people with Medicare needing these services do not receive them.

    7.     Do you have a living will and medical power of attorney, Advance Directives? You should. Get help from Caring Connections.

  • How to get health insurance when you’re ineligible for both Medicaid and premium assistance in the state exchange

    How to get health insurance when you’re ineligible for both Medicaid and premium assistance in the state exchange

    Because the Supreme Court gave states the option of expanding Medicaid, it has forced about four million people today into an insurance no man’s land. These four million people live in states that have still chosen not to expand Medicaid. They have incomes too high to qualify for Medicaid and too low to qualify for a subsidy in their state exchanges. The federal government does not subsidize premiums of people who earn less than the federal poverty level in the state exchanges.

    The twenty states that have not expanded Medicaid to date have made it very hard for people caught in this “coverage gap.” Medicaid can be a life-saving benefit.  And, unless people in this coverage gap move to a state that has expanded Medicaid, they are ineligible for it. Today, more than half a million people cannot get needed mental health care because they live in states that have not expanded Medicaid.

    If they stay put, to get health insurance, people in states that have not expanded Medicaid have no choice but to take on more work. That can mean working two full-time jobs. But, according to the Kaiser Family Foundation, more than half of people caught in this gap have full-time or part-time jobs already and 86 percent of them live in the south.

    In Texas, to qualify for Medicaid, your income must be less than 20 percent of the federal poverty level. Only if people can raise their income above 100 percent of the federal poverty level will the federal government pick up a large percentage of their insurance premium through the exchange.

    To apply for a subsidy in the state exchanges, you must project your annual income. Fortunately, if your income ends up being less than the federal poverty level, the current rules do not require you to pay back the subsidy. For free or low-cost resources in your community, click here.

    People who are uninsured because their states have not expanded Medicaid must complete a form to avoid paying a penalty for not having insurance.

  • Four things to think about before moving into a nursing home

    Four things to think about before moving into a nursing home

    Before moving into a nursing home, it’s important to do your homework and understand your rights and options.

    1. Care: You have the right to receive whatever care you need to reach the highest reasonable level of functioning or so that your condition does not deteriorate.  Medicaid patients have exactly the same rights to these services as everyone else in the nursing home so long as the nursing home accepts Medicaid patients. And all patients and their families have the right to help develop the care plan so that it is tailored to the resident’s needs
    2. Choice: The nursing home must accommodate the resident’s preferences, whether they be to wake up late in the morning, to participate in an activity, to change schedules or to have family visit any time of the day or night.
    3. Costs: Only the resident is required to be financially responsible for his or her care.  The nursing home cannot force a family member to take responsibility.  Medicare should pick up the costs for residents needing daily skilled nursing or therapy care who have been hospitalized for three days in the 30 days prior to admission, so long as the nursing home is Medicare-certified.  If the nursing home says Medicare won’t pay, you still should insist that it submit the bill to Medicare.
    4. Help: Every state has a long-term care ombudsman program to help ensure the nursing home provides you with the benefits and protections to which you are entitled free of charge. There are also websites where you can find nursing home ratings, but read them with caution.
    For more information from the National Senior Citizens Law Center, click here.
  • Four things to think about regarding Medicaid estate recovery

    Four things to think about regarding Medicaid estate recovery

    If you have Medicaid, you will likely have low health care costs.  However, in some instances, after you pass, your state may attempt to get back some of those costs through Medicaid estate recovery.  That could affect what your heirs inherit.  You should understand what your state might do.

    1. Rules: Children may not be able to inherit the home of a parent for whom Medicaid has covered medical costs. Federal law requires that states recover Medicaid costs from the estates of some Medicaid patients and allows states to recover these costs from the estates of other Medicaid patients.
    2. Process: Each state has different laws on whether it will impose a lien on a Medicaid patient’s property.
    3. Timing: States cannot recover any Medicaid costs from the sale of the home of a Medicaid patient living in a nursing home until the patient and his or her surviving spouse living in that home have passed away or the property, which the state has claimed a stake in, is sold.
    4. Waivers: States must have procedures for not taking money from a Medicaid patient’s estate when it would cause undue hardship.
    For more information on Medicaid estate recovery, go to the National Health Law Program here.
  • It’s time to enroll in a health plan if you are under 65

    It’s time to enroll in a health plan if you are under 65

    Open enrollment in state health exchanges begins on November 15 and lasts through February 15.  You can enroll in a health plan or switch health plans even if you have costly health care needs.  Health plans cannot cancel your coverage if you need costly health care. Here are four things to keep in mind:
    1. Help with premiums: If your income is no more than four times the federal poverty level (between $11,670 and $46,680 for an individual or $23,850 and $95,400 for a family of four), you are eligible for help with the premiums.
    2.  Automatic reenrollment: If you have health insurance through an exchange and do nothing, you will be reenrolled in the same health plan.  But, if you’re smart, you’ll visit healthcare.gov to see whether there are any new plans in your area and what your current health plan is offering in terms of costs and benefits as compared to other health plans in your area.  Read these tips for choosing a health plan.
    3. Expanded Medicaid eligibility: If your income is at or below 138 percent of the federal poverty level ($16,105 for an individual and $32,913 for a family of four) in many states you are likely eligible for Medicaid
    4. Penalty if you go without health insurance: If you did not have insurance in 2014 or if you don’t have insurance in 2015, you will pay a penalty when you file your federal taxes.  In 2014, the penalty is $95 or 1% of your income, whichever is higher.  In 2015, the penalty is $395 or 2% of your income, whichever is higher.

    If you enroll after the 15th of the month, your coverage will not begin until a month and a half later.  If you enroll between the 1st and 15th of the month, your coverage will begin on the 1st of the following month. For more information, check out the Kaiser Family Foundation’s Consumer Guide.

    If you like this post, you might also like these:
    Four tips for keeping your costs down in a private health plan or Medicare Advantage plan
    A crash course in five important health insurance terms