You may find yourself in the role of a caregiver if one of your loved ones needs help with managing their health care with Medicare. As a caregiver, you will be making important decisions and suggestions so it is important to obtain an understanding of the benefits covered by Medicare plans and how Medicare works.
Understanding their Medicare Coverage
When you do find yourself in the role of a caregiver, you should learn about the needs of the beneficiary such as their prescription drugs, who has permission to act on their behalf and the type of care they need.
Learn about the beneficiary’s current health insurance plan. Do they have Original Medicare, a Medicare Supplement plan or Medicare Part C? Do they have prescription drug coverage? If the beneficiary has a Medicare Advantage plan, they should have a membership card where you can find this information.
If you cannot locate the beneficiary’s Medicare card, you may contact Medicare together to find out their coverage or fill out a form to have their information released to you. You may contact Medicare at 1-800-633-4227 (1-800-MEDICARE) (TTY 1-877-486-2048).
Here is a checklist of helpful items to have about the beneficiary available that is helpful.
- The location of the beneficiary’s medical power of attorney, financial information and living will
- Social Security number
- Current list of prescription drugs the beneficiary is taking along with doses and any other herbal and over the counter medication
- Any other insurance policies such as long term care
- A list of food and other allergies
- Contact list of current doctors, pharmacists and nurses
- Health history
- Type of Medicare coverage and number
- Emergency contacts
- Current health conditions, symptoms and treatment
Paying for Health Medicare
Find out if your beneficiary has additional coverage other than Medicare. Other insurances such as Medicaid or health plans from a former employer may help pay for care.
The beneficiary may be eligible for additional programs to help pay for health costs depending on their income. The Medicare Extra Help program offers subsidies for prescription drugs. Check with your state to see if your beneficiary qualifies for the Medicaid programs to help with long term care and medical expenses for low income families and individuals.
Hospitalization and Illness
Being emotionally supportive is an important part of managing a beneficiary’s care especially if the beneficiary has a chronic health condition. It is important for the caregiver to speak openly with the beneficiary about the treatment, illness and what the doctor says during a visit may provide relief to concerns about the beneficiary’s situation.
It is important to understand the coverage of Medicare Part A for hospitalization. Obtaining a second or third opinion if a beneficiary’s doctor suggests a major medical test or surgery should be encouraged. The importance of obtaining a third opinion becomes greater if the second opinion differs from the first. This will help the beneficiary decide on the best course of action.
If a beneficiary has Medicare Part A and Part B wants to see a specialist or get a second opinion, they do not need a referral from their doctor. If a beneficiary has Medicare Part C, some plans, such as HMOs, may require a referral from their doctor to get a second opinion.
If a beneficiary has Original Medicare, you should ask your medical supplier or doctor if they accept “assignment” before proceeding. “Assignment” is an agreed Medicare approved amount for payment for Medicare doctors, suppliers and health care providers. The beneficiary will need to pay their cost such as co-insurance, deductible or co-payment if the doctor or supplier accepts “assignment”.
When a beneficiary must be hospitalized, Medicare will cover for inpatient care when the following are met:
- Medicare has an agreement with the hospital
- In order to treat the beneficiary’s illness or injury, the doctor says that inpatient hospital care is necessary
- Only a hospital can provide the Medicare beneficiary with the kind of care they need
- While the Medicare beneficiary is in the hospital the Utilization Review Committee approves the stay
When the beneficiary is hospitalized, Medicare will not pay for:
- Hospital services — telephone and TV
- Care – Nursing via private-duty
- Room – Unless medically necessary, private room
- Personal care – Toothbrush and shaving razor
When the beneficiary is hospitalized, Medicare will not pay for:
- Hospital Services – Most supplies and services, meals
- Care – nursing (general)
- Room – Semi-private
Please visit www.medicare.gov for more information about Medicare Part A coverage.
Prescription Drug Coverage
Beneficiaries with Medicare wishing to get prescription drug coverage can join a prescription drug plan offered by a private insurance company. Drug coverage and costs vary among prescription drug plans so the beneficiary must choose carefully.
A Medicare beneficiary may obtain prescription drug coverage via two ways, Medicare Advantage Prescription Drug plan (MAPD) or Medicare prescription drug plan (PDP)
- Medicare Advantage Prescription Drug plan – A Medicare beneficiary who wants to obtain a Medicare Advantage plan must have Original Medicare. A Medicare Advantage plan may include prescription drug coverage and a beneficiary may be able to get their prescription drugs through this plan.
- Medicare prescription drug plan – A Medicare beneficiary who wants to obtain a Medicare prescription drug plan must have Original Medicare and live in the service area of the Medicare prescription drug plan.
Additional Prescription Drug Coverage plans
If a beneficiary has additional health care coverage such as veterans benefits or employee health care through your employer, the beneficiary may already have prescription drug coverage. To determine which insurance pays first, Medicare uses a guidelines called “coordination of benefits”. To find out more about how “coordination of benefits” works, call the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY 1-855-797-2627).
Here are other types of drug coverage a beneficiary may have:
- TRICARE – the Federal Employee Health Benefits Program (FEHBP) or the Department of Veterans Affairs (VA).
- Union or Employer Sponsored Drug Coverage – a beneficiary may be able to get drug coverage through if they are enrolled in a union sponsored or employer plan.
Before you make any changes to the beneficiary’s drug coverage, you should contact the plan’s insurer or administrator. Obtaining a Medicare prescription drug plan may alter how the coverage works for the beneficiary or dependants covered under their current plan.
What does a Medicare prescription drug plan cover?
Both Medicare Advantage Prescription Drug and stand alone plans have a list called a drug list, or formulary that contains the prescription drugs they cover. Brand name or generic prescription drugs may both be covered under the plan.
Be aware of the rules for the Medicare drug plan such as quantity limits, prior authorization and step therapy.
- Quantity limits – determines the amount of doses or pills a beneficiary can receive at a time,
- Prior Authorization – before certain prescriptions can be filled, the doctor and/or the beneficiary must contact the plan.
- Step Therapy – the beneficiary is required to try drugs at a lower cost before the plan will cover the doctor prescribed drugs.
These drug coverage rules may be waived upon the doctor’s request for an exception.
Choosing a prescription drug plan
A beneficiary has several Medicare prescription drug plan options. As a caregiver, you can help them decide a prescription drug plan that provides the coverage they need at a price they can afford. For more information, please:
- Contact us by clicking here
- Call 1-800-Medicare (1-800-633-4227) (TTY users 1-800-325-0778).
- Print copies of “Your Guide to Medicare Prescription Drug Coverage.” from www.medicare.gov
- Call the State Health Insurance Assistance Program (SHIP) in your state.
Every Fall the “Medicare & You” booklet is mailed out to all Medicare enrollees which contains information about prescription drug plans for Medicare in your area.
Continuing care
Continuing care options covered under Medicare are listed and explained below:
Home Health
The skilled at home short term health care to treat injury / illness or after hospitalization may be available by some health agencies. These agencies may include, and are not limited to, medical social work, occupational therapy, skilled nursing care, speech therapy, physical therapy and home health aide care.
To qualify for Home Health, the beneficiary must meet the following conditions:
- The health agency the beneficiary chooses must be a Medicare approved, Medicare-certified, agency.
- The doctor for the beneficiary has produced a plan for medical care at home and has deemed it medically necessary.
- The beneficiary is homebound meaning the beneficiary requires considerable effort to leave their home or the beneficiary cannot leave their home without assistance.
- It is medically necessary for the beneficiary to receive one or more of the following:
- continued occupational therapy
- intermittent skilled nursing care
- speech-language pathology
- physical therapy
Beneficiaries may still get home health care if they leave home for medical treatment, attend adult day care, or short trips such as a religious service. To find more information about home health eligibility, call 1-800-MEDICARE (1-800-633-4227); TTY users can call 1-977-486-2018 or visit www.medicare.gov.
Certified health agencies must meet federal safety and health requirements. Medicare offers a tool to find a home health agency near you http://www.medicare.gov/HHCompare/Home.asp.
Housing and nursing homes
If the beneficiary has a chronic or serious illness, they may need full time care outside their home. There are facilities that provide this service and range from part time or full time care listed below:
- Adult Day Care – Provides services during the day and the beneficiary returns home in the evening. A protective environment with activities and rehabilitation is provided on a daily basis.
- Independent Living Facilities – Provides settings for beneficiaries to live independently and coordinates support such as recreational and social activities as well as meals.
- Skilled Nursing Facilities – Provides high level care with 24 hour supervision for patients who need rehabilitative and medical services.>
- Continuing Care Retirement Communities (CCRC) – Provides different levels of care based on the needs of the beneficiary within a housing community.
- Custodial Care – Provides daily activity assistance such as meals, dressing and bathing.
- Assisted Living Facilities – Provides limited assistance with daily living tasks such as medication management and cooking for beneficiaries living in residential homes within the facility.
- Nursing Homes – Provides health and personal care services to people living in the facility as a permanent resident. Nursing home residents may have emotional, physical and/or mental problems and may be too sick or frail to live on their own and require daily living assistance.
Hospice Care
Hospice Care is special care for people who are terminally ill or dying. The objective of Hospice is to provide end of life care and relief of pain. Typically, patients receive hospice care within their homes, however; hospice care may be administered in Medicare approved facilities depending on the condition of the patient.
A patient must have Medicare Part A to be eligible for hospice care and:
- The beneficiary must sign a statement stating they choose hospice care as opposed to regular Medicare benefits
- The doctor for the beneficiary certifies that the beneficiary has a terminal illness and has six months or less to live.
- A Medicare approved hospice program is administering the care to the beneficiary.
If the health of the beneficiary improves or their illness goes into remission, the beneficiary may choose to return to a regular Medicare plan.
Call 1-800-Medicare (1-800-633-4227) (TTY users 1-877-486-2048) to find a hospice program.
The content in this article is for informational purposes only.