Be Sure to Read the Small Print

Usually I toss my copy of the annual Medicare and You Handbook into my ‘read file.’ But with our book coming out in January (see below), I carefully reviewed this year’s issue. Its 122 pages are chock-full of information on coverage like chronic care management services (p.34) and yearly wellness visits (p.49). But the following three items, I believe, merit special attention.

1. Medicare covers voluntary advance care planning with your health care professional (p. 30) as part of your yearly “Wellness” visit. Advance care planning includes creating a living will (or advance directive) that specifies the care you would want should you become unable to speak for yourself or make decisions about your care at some future time. Medicare will reimburse your doctor for discussing possible end of life treatment options such as palliative care, intubation, and other measures should you be unable to decide for yourself.

Although the Handbook doesn’t mention having ‘The Conversation’ about these issues with family members, we urge that you discuss your end of life treatment preferences with them. The Handbook also doesn’t cover the need for you to designate a health care power of attorney (or health care proxy or agent), i.e., the person whom you entrust to make treatment decisions if you lack capacity to do so. However, this should be part of your advance care planning conversation(s) with your medical professional and family members.

2. The Handbook distinguishes between in- and out-patient hospital status (p.28). You must be admitted to a hospital to qualify for post-hospital residential skilled nursing or therapeutic care (see below). Medicare requires hospitals to inform you if you are an outpatient (or there ‘for observation’) as opposed to being ‘admitted’. After seven days’ hospitalization for a broken ankle, (but not admitted as an ‘in-patient’), Carolyn had to undergo weeks of skilled nursing care. While Medicare covered her therapeutic treatment, it did not pay her residential expenses. Remember: your doctor must order your hospital admission, and the hospital must formally admit you.

3. As discussed above, Medicare will cover skilled nursing and rehabilitative care (p. 28) if:

– you were admitted to a hospital for a medically necessary, minimum three-day stay (not including discharge day);
– your doctor certifies that you need daily skilled nursing or skilled therapy which can only be provided in a skilled nursing facility;
– coverage is necessary to help improve or maintain your current condition.

Note the word maintain. For years, many facilities only provided care if a patient’s condition improved. A 2013 court settlement (Jimmo v. Sebelius) called for Medicare to clarify that coverage will not depend on a beneficiary’s potential for improvement from therapy, but rather on the beneficiary’s need for skilled care so as not to get worse.

The Handbook provides other valuable information. If you or a family member is on Medicare, take time to examine this valuable resource.

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Our book Love’s Way: Living Peacefully with Your Family as Your Parents Age will be published in January, 2019, by Hendrickson Publishers. Order it now from Amazon, Barnes & Noble, or ChristianBooks. Publisher says it will be available in time for Christmas for those who pre-order.