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The Medicare agreement to expand its skilled nursing care and rehabilitation therapy benefit for people with certain chronic diseases such as stroke, dementia, neurological illnesses. This added care, which came in a settlement of a lawsuit brought by a Vermont woman named Glenda Jimmo, the Center for Medicare Advocacy, and others important for some Medicare beneficiaries.
The settlement does not affect long-term care benefits in any way. Medicare does not pay for nursing home care, home health aides, or other long-term care services before this lawsuit, and it will not do so now.
In addition, the case has no impact on Medicaid. This program program does pay for services for people who are both impoverished and need a high level of caregiving assistance. The benefits and eligibility rules for Medicaid remain unchanged.
This agreement will make it easier for some people who are receiving long-term care services to receive for longer periods of time, skilled nursing care or physical therapy. But it will not require Medicare to pay for custodial long-term services.
Many people do not understand Medicare benefits for those with chronic disease. Does this mean that people needing many types of caregiving services may now get Medicare long-term care benefits? The direct answer is: No.
The settlement is important. For years, many home health agencies and skilled nursing facilities have interpreted Medicare rules to mean the program would not pay for rehab if a patient is not getting better.
Consider, for example, a 77-year old suffers a stroke. There has been no question that Medicare could pay for, say, their physical or occupational therapy. However, the rules have been unclear, and many providers have taken the position that Medicare would pay as long as the person improves as a result of this skilled care.
The rules were vague, and Medicare has sometimes argued that providers misunderstood them. Still, many service providers, who feared Medicare auditors would demand repayment for ineligible services, were reluctant to provide rehab or skilled nursing unless a patient met this “improvement standard.”
Under the terms of the legal settlement, a doctor no longer has to assert that a patient will improve to be eligible for skilled nursing care and rehabilitation. The insured will now be eligible for Medicare benefits even if that care helps them maintain their health status. As long as skilled care is considered necessary by a health professional based on an individual assessment, maintenance therapy would now be a Medicare benefit.
It is also important to remember that the settlement does not increase the number of days skilled nursing care is provided after a hospitalization. It remains a maximum of 100 days per benefit period.
The agreement must still be approved by the judge before it is final.
It is past time for Medicare to clarify this issue, and it may end up saving the program money since ongoing therapy might keep people with chronic diseases out of the hospital. However, don’t be confused: This agreement does nothing to expand long-term care benefits.
Myth 1: Medicare’s will cover me.
For the same reason that your regular health insurance will not cover long-term care, Medicare won't cover most long term care services. It is a financial and planning misconception that will leave the consumer paying for long-term care using their present cash flow to pay for caregiver services.
Myth 2: My spouse or children will take care of me.
What happens if your spouse also needs long-term care or you are single or your children move far away or are too busy or can not afford to take time off to provide the care you need? Demographics and family situations have changed in today’s modern, mobile workforce. You simply can’t rely on your family, children, social services, or service organizations to provide this kind of care.
Myth 3: Long Term Care Insurance companies provide the only solution.
Not always. Though purchasing a Long Term Care Insurance policy from a reputable private carrier still remains the best defense against your future long-term care needs. If you have assets of many millions you may have sufficient cash flow to pay for caregiver services. If you are without sufficient you may qualify for Medicaid benefits.
Myth 4: Your premiums will never rise.
This is both false and simply not pragmatically possible. But, any increase in premium costs need to be weighed against the very high cost of long-term care.
Myth 5: I can wait until I retire to decided.
While it’s never too early, or late, to purchase a Long Term Care Insurance policy, it can be vastly more expensive if you wait until you are in your 60s.
There is another trend which the consumer does not grasp. Owning a plan now offers benefits which may not be available in future years. It maybe thought of as a sales tactic but this is correct – until interest rates rise, insurance companies may continue to raise premiums for plans purchased years ago or even a few years ago and flexibility of benefits may not be as generous as they are in present plans.
Myth 6: It only covers nursing homes.
Plans are now comprehensive meaning care services are provided whether you are living in your home or in a care facility whether by choice or circumstances.
Myth 7: Elimination period” is a waiting period.
It is a deductible between the time you qualify for care services and when you begin to receive long term care benefits. There are riders which will provide immediate benefits if caregiving services begin at home.
Myth 8: I cannot afford Long Term Care Insurance.
This is usually not correct and more of denial then true. Some people have a ”maybe it will happen maybe it will not happen why bother” approach to long-term care planning. Even modest policies from reputable Long Term Care Insurance companies may mean the difference between getting the care you need and financial and emotional stress for those who need care giving and those who are caregivers.
To those who comment: “I am in good health, I do not need to own long term care insurance” is contradictory to what happens in our lives. In addition, once you have chronic health issues – you will no longer be eligible to be considered for a plan
whether it is a traditional or hybrid LTC plan.
Myth 9: It does not matter who sells me a plan.
There are many people who will recommend and sell you a long term care plan: financial planners, general insurance agents, and other advisers.
Long term care insurance is a specialty benefit product. There are a variety of carriers and options to consider based on health, financial suitability, and what you want to accomplish. Consult with an informed extended care solutions planner who is competent and knowledgeable with underwriting requirements and carrier benefits.This is an extended care benefit you and your family “need to get right the first time.”