Medicare has 3 basic parts, Part A, Part B, and Part D.  So when an individual turns 65, and they have worked their mandatory 40 quarters, and “paid into” the system, they automatically get Part A.  They then have to sign up for Part B, and Part D is not mandatory, but if you do not have a secondary Part D plan, or another drug or prescription plan through an old work plan, medicare will penalize you for every month you don’t employ a Part D.

Now, when a PALS is diagnosed with ALS, they can qualify to get Medicare, even if they aren’t 65 and even if they haven’t worked their 40 quarters.  At this point the PALS needs to contact social security, and medicare to get the ball rolling, and to talk to them on how they qualify.  Now, even if you have a secondary insurance through work, for example, I still would recommend getting your medicare in place.  One less thing to do later, when things will really start to get complicated.

Social Security 800-772-1213

Medicare         800-633-4227 

Part A covers hospital care, skilled nursing facilities, nursing home, hospice, and in home health care.

Part B covers medically necessary services, and preventative services.  This may include but is not exclusive to inpatient and outpatient services, doctors visits, and ambulance services. 

Part D is the drug coverage that is provided by medicare, and it has 3 different plans that you could employ.  Medicare also has a drug finder, on the website, where you can put in all of your drugs, on the website, and see what is covered, and what plans will cover what drugs.  Here is the link to themedicare.gov that explains the coverage…

http://www.medicare.gov/what-medicare-covers/index.html

Now there are secondary insurance plans provided by insurance carriers are called MA or Medicare Advantage Plans, and Medicare Supplements or Medi-Gap Plans.  MA Plans are HMO plans, that include Part D, and generally cover almost everything, that original medicare doesn’t cover, because there are some things that require a co-pay, on Part B.  MA Plans require a PALS  to find a network that has all of his or her doctors in the network.  They would then have to find a primary care physician that is sensitive to ALS, so that the communication between each of the doctors is efficient and that they are on  the same page.  This is the main challenge with a PALS being on an MA Plan, because it is Managed Care, or an HMO.  But what makes these plans savory, to a PALS, is that they cost near to nothing, as far as the premium goes.  Most MA Plans cost $0, which can be very helpful on a PALS budget.  But please investigate what plans are in your area and the costs of those plans.

Medicare Supplements can be a more savory option for a PALS, because it is a PPO, which means as long as the doctor and facility, takes original medicare, they will accept a medicare supplement,  meaning the PALS is not connected to a specific network, like an HMO Plan.  But, there is a cost to these plans, and they DO NOT include Part D or the prescription drug portion, so when buying a supplemental plan, a Part D plan will also have to be purchased.  Now there are a lot of medicare supplements on the market.  I like Part F, because it covers everything.  The only out of pocket cost, is going to be the monthly premium.  But a monthly premium, could be a hard thing to come up with, for someone on a budget.  Supplemental plans also give you the freedom to move about the country, and see different doctors.  So, for example, if a PALS is early on in their diagnosis, they then can seek out different opinions from different doctors.  An MA Plan restricts you to your network.  So, as you can see, there are many moving parts, and there should be much consideration put into, what plan you eventually want to go with.  But of course, the decision to employ a secondary plan, and WHAT plan to purchase, is dependent on the PALS personal, medical, and financial situation, and the options should ALWAYS be discussed with the PALS family, doctor, and a licensed insurance agent, that knows the plans designated to the area.

Finally, I will discuss in home health care.  These people can be extremely helpful for a family that is struggling with the day to day duties of living life, and taking care of a PALS.  PALS and their families, also have to be accepting of home health aids, and skilled nursing.  So many times a family will say they want help, but the PALS will say that he or she only wants their spouse to be their caregiver, because they are the ones who they feel the most comfortable with.  Now, I understand this mentality, but things will get complicated, and if you only have one person, doing all of the “dirty work”, it willcause stress, and a strain on the house hold.  Accepting this in home help, will keep all of the relationships intact, and authentic.  It is very important for a PALS and their family to accept help, from anyone, if they are to keep the ship moving in a positive direction.  This lesson I learned firsthand from my friend, Steve Gleason.  He was very accepting, and would let anyone help him, that wanted to help.

To get home health care help, a doctor has to sign off on it, and that it is medically necessary.  The doctor has to prescribe intermittent skilled services, and a home health aid.  So this is basically a letter of recommendation that the doctor writes, to the insurance carrier and/or medicare, to get the service started.  From here, the doctor, and/or the doctor’s office, and/or the insurance carrier should be able to help the PALS find a Medicare Certified Home Health Agency that is in the network, to get the services started.  The PALS will then be prescribed a certain amount of hours a week to have a therapist come over, to do physical, occupational, and speech therapies.  While a health aid helps with the basics of getting the PALS out of bed, bathing, and dressing.  This can free the primary care giver up, to do other “life” activities, so they can keep the ship moving.  The intermittent skilled nursing services are the key, and must be done to insure that the home health care services will continue.  According to medicare rules, you can’t have the help of a health aid, without having the intermittent skilled services of a therapist.  Plus, these therapies are very beneficial, to continue to stonewall the disease physically and emotionally.  To continue to get in home health care services, there has to be clear communication with the doctor, so they can continue to write the letter of recommendation, because there is no cap or limit as to how much home health care one can get.  Here is an excerpt from the Center for Medicare Advocacy website…

• Home Health Care

Unlike the Medicare skilled nursing facility benefit, which provides coverage for a short period of time, Medicare coverage can be available for long-term home health care if the qualifying criteria are met.  There is no legal limit on the duration of time for which home health coverage is available.  Further, Medicare covers home health services in full, with no required deductible or co-payments from the beneficiary. Services must be medically necessary and reasonable and the following criteria must be met

Here is the link for the CMA website, and the page that will explain this particular benefit.

http://www.medicareadvocacy.org/medicare-info/chronic-conditions/introduction-to-medicre-coverage-for-people-with-multiple-sclerosis

Please be aware that this page is for people with MS, but pay no attention to that, because the benefits are the same for PALS, as well.

Also, keep in mind, when the doctor does write the letter of recommendation, medicare might deny the claim.  DO NOT ACCEPT THE DENIAL!  Many times, it comes down to how the letter was written, and if the correct procedure codes were used.  This is a common mistake that happens, when requesting these services.  So fight through it, and insist that the doctor revisits the letter and make sure they are giving the proper codes for this “medically necessary treatment”.  So I always encourage to find the right doctor, that is on the same page as you are, so that the communication is clear, and that you all have the same focus.

Also, MA Plans, Supplemental Plans, and Drug Plans constantly change.  So do your due diligence and make sure you are aware of the changes to the plans, and the drug formularies, related to medicare secondary plans, because these changes happen on a year to year basis.  And always makes sure you know the benefits.  That way you will be in front of any erroneous costs.

To conclude, please keep in mind, that not every situation is the same, and that this blog is to raise awareness about the options that you have, in regards to your health care.  Medicare can be a huge monolith of information, that seems impossible to scale, but it is possible to use medicare in a easy and beneficial way.  If you have questions, please seek out a licensed insurance agent in your area, because they are going to know the plans and the specifics of those plans, in your particular area.   There are also many carriers that offer many plans, so talking to an agent will help you find the right plan for you.

Helpful links:

Medicare’s official website                                                            

http://www.medicare.gov

Center for Medicare Advocacy, or CMA is a “watch dog” group   

http://www.medicareadvocacy.org

No White Flags

JD Ward