July 2018 Healthcare Forum

When did you first realize you were growing older? Were you in your fifties and received an invitation to join AARP (and you thought you had to be 65), or was it when you could no longer run a four-minute mile and settled for a fifteen-minute walk? You guessed today’s topic!

For July’s healthcare forum we’ll begin the first of a four-part series focusing on the healthcare and insurance needs of those of us in our 60’s and 70’s. Younger readers may benefit by having a better grip on the healthcare needs of their parents/grandparents and learning about healthcare issues they’ll need to wrangle with when reaching the so-called “golden years.”

For this month’s forum (Part I), we’ll discuss improvements to Medicare you may not be fully aware of.

For the August forum, Part II, we’ll concentrate on those of you who currently have or are about to begin Medicare and provide “inside” strategies to select the most cost-efficient Medicare plans.

Part III will focus on those of you age 63-65 who want to learn the “ins and outs” of Medicare so you can select the best plans and consider revising those choices in subsequent years.

For Part IV in October, we’ll share musings from your septuagenarian doctors/authors about what life is like in the 70’s (we like to think of it as the new 50’s.) We hope you’ll find it amusing and informative.

Improvements to Medicare

Free Yearly Medicare Check-up(s)

Thanks to President Obama’s Affordable Care Act (ACA), those on Medicare are entitled to a free annual medical checkup and if your doctor believes it’s warranted, free screening tests such as a mammogram, screening for colorectal cancer, and other tests. Neither your Part B Medicare nor you will be charged. You’re also entitled to an additional free annual “wellness visit” to discuss with your doctor more detail about your health concerns. When making an appointment for either or both of these “free visits,” ask the office manager if these doctor visits will indeed be free.

Improvements to Your Drug (Part D) Plan – The Good News

What is the doughnut hole? After you and Medicare have paid out a certain amount of money for your medications during a calendar year ($3,750 for 2018,) you enter the doughnut hole when you pay 35% of the cost of brand and 44% of the cost of generic medications until your our-of-pocket (o.o.p.) spending reaches $5,000 for the year (an additional $1,250 o.o.p.) After that, you pay no more than 5% of drug costs until year end. In 2019, you’ll pay 25% of the cost of brand name medications while in the doughnut hole.

The Bad News About Medications

The bad news about the cost of medications, especially for brand name medications, is that they are projected to increase about 6.5% per year. In our August forum, we’ll discuss strategies for reducing your out-of-pocket cost for medications by carefully selecting and then reviewing annually the best Plan D for you.

Limits on the Extent of Rehabilitative Services Now Removed

The following may be especially relevant if you or a family member is, or will be, receiving physical, occupational, or speech therapy and is suddenly informed that Medicare has paid their maximum amount. In other words, therapy will need to end. If you believe rehab therapy should continue, read on!

There was a long-standing erroneous belief that for Medicare to pay over a fixed dollar cap for rehabilitation, a patient needed to demonstrate “improvement.” But in 2013, the “Jimmo” Settlement agreement was reached between a patient (and family) and the Centers for Medicare and Medical Services (CMS). The agreement stated that Medicare would continue to pay if therapy was needed to “maintain, prevent, or slow deterioration.” Jimmo is not limited to patients with specific illnesses, and it applies to patients who have regular Medicare or Medicare Advantage plans.

Another major development in support of extending rehab therapies is the recent (Feb 2018)[1] permanent repeal of payment caps for outpatient rehab therapies, which was part of the recent federal tax law.

So, you have both the Jimmo agreement and the tax law to support your case. Because many doctors and rehab programs may not be totally familiar with these developments, show these documents to the doctor or administration of the rehab program. You may have to advocate aggressively for the care you or a family member think is needed and enlist your physician to intervene on your behalf.

Advice about challenging a denial of continued rehab services can be found on the Patient Advocate Foundation website[2] or from a lawyer specializing in healthcare law.

For the August forum we’ll be discussing cost saving strategies and the “ins and outs” of Medicare for those of you who already have, or are about to join, Medicare.

Please send us questions about this month’s forum or other problems you are grappling with about getting quality care from our complex healthcare system. Answers to some questions will be posted next month. We’ll respond personally to other questions if you provide your email address.

Please post questions/comments below, and follow and Like us on Facebook at: www.facebook.com/QualityAffordableHealthcare. We cannot answer questions about your personal medical issues because of medical/legal restrictions and because they are best addressed by your doctor.

If you have family members or friends you think may benefit from our monthly healthcare forums, please forward this to them. If they would like to regularly receive our forum, they can sign up on our mailing list below.

Please watch for updates about our forthcoming book: “Doctors’ Inside Guide to Quality Affordable Healthcare.”

[1] www.aarp.org-Feb.9, 2018.

[2] www.patientadvocate.org or tel. 800-532-5274.

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