We all know that health care is big business. Just look at how it continues to change under the pressure of government regulation, subsidies, consolidation, and competition among private insurance companies and health care providers.
The lack of financial resources for long-term care services usually causes elder law attorneys to focus on chronic care at home or in a nursing facility. However, there are many other issues to consider when looking at acute (non-long-term) care payment coverage options.
For the elderly and disabled, many consumers have relied upon traditional Medicare. In the past few years, the above pressures have produced not only different types of Medicare, such as Medicare Advantage plans, but also different options to obtain coverage altogether. With new options and choices to consider, the phrase “timing is everything” is appropriate.
Let’s examine some options while recognizing that these options may be able to be used in conjunction with others.
1. Medicare – The traditional government health insurance program is available to people age 65 or who have been disabled for two years. There are now many options involved in selecting the right Medicare plan. The key is to understand that there are “windows” of time for selecting a plan and options and there are other restrictions for switching plans.
For a disabled person receiving Medicare under age 65, certain choices for coverage are available, which if missed, may not be available again until the person turns 65. What if a person needs a certain drug or procedure not covered by Medicare? Can one “dis-enroll” to seek better coverage through one of the other options below? If so, does he/she runs the risk of losing these benefits forever? What about having to pay back the government for benefits already received?
2. Private Insurance – As stated above, for some, Medicare or a Medicare Advantage plan may just not provide the coverage of a private insurance policy. So, it is possible to simply purchase private insurance that better fits the person’s needs.
However, a private insurance carrier will require that a person is not enrolled in Medicare prior to enrolling with a private plan. Once again, all the various financial and coverage issues need to be examined – preferably before age 65 or shortly after the onset of a long-term disability.
3. Affordable Care Act – Even with all the heated political debate in an election year, for now, “Obamacare” is still with us. Love it or hate it, the new law provides options for those who cannot otherwise obtain health insurance. This can be very helpful for people with pre-existing medical conditions. Without the ACA, those wanting coverage might have to move to the next option: Medicaid.
4. Medicaid (Medical Assistance in PA) - Medical Assistance in Pennsylvania provides a wide variety of health care coverage options, especially for children. (The financial eligibility rules are greatly relaxed for parents of children who need care.)
Medicaid provides other useful programs, such as the Medical Assistance for Workers with Disabilities program. This allows people who are technically disabled, but want to continue to work, to have greatly reduced premiums for comprehensive healthcare.
In addition, there are circumstances where a person could qualify for both Medicare and Medicaid, thus being known as a “dual eligible.” Each Medicaid program has very specific guidelines, which may change annually. So, it’s important to verify eligibility based on specific circumstances.
Sound confusing? Fortunately, some excellent resources to learn in more depth about these options are just a phone call or click away.
In the Pittsburgh area, contact the Apprise counselors at (412) 661-1670. Apprise is a free service offered through the Pennsylvania Department of Aging.
Julian Gray and Frank Petrich are both certified elder law attorneys who practice in the Pittsburgh area at Gray Elder Law. Send questions to firstname.lastname@example.org or visit www.grayelderlaw.com.