The Alphabet Soup of Medicare

by Lisa Bayer, J.D., CCM

It is open enrollment time for Medicare supplemental plans and anyone who has tried to navigate the process is faced with a myriad of choices and terminology. There’s Medicare A, B, C and D. Part A is your inpatient insurance, Part B is your outpatient insurance and Part D is your prescription drug coverage. Part C is sort of a combination of A, B and D and these plans are known as “Medicare Advantage” plans.

If you do go the traditional Medicare route and you are considering a Medigap policy (a supplemental plan that helps to fill in Medicare coverage gaps) you could be looking at another mouthful of letters! For the heck of it I put in our zip code and the Medigap plans available in LMR Elder Care’s area, 07039, include A, B, C, D, F, G, K, L, M and N. And if that is not enough would I want a high deductible or “regular” Medicap plan? So how does one decide? To start, make a list of your medications and medical providers. Next, enter your information at www.Medicare.gov, access a state SHIP counselor (a volunteer trained to provide objective Medicare benefit counseling - https://www.state.nj.us/humanservices/doas/services/ship/ - in New Jersey), or get in touch with a private insurance representative that can help you select a plan at no fee to the Medicare beneficiary.

It is important to note that if you are not subject to a special enrollment period this is the only time of year that you will have the opportunity to review, and possibly decide to change, your supplemental insurance and prescription drug coverage. As Eric Cohen, Managing Director of Benefit Quest, Inc points out, “It’s important to sign up at the right time if you want to make any changes or adjustments to your health coverage or your prescription drugs.” For 2021 this review period takes place from October 15 through December 7, 2020.

Managing a Hospital Stay - "MOON" (part 1)

by: Lisa Bayer, J.D., CCM, Advanced Professional member of the Aging Life Care Association

Me: “Is she on observation status or a formally admitted inpatient?”

Client’s son: “My mom is in a private room. She was admitted yesterday evening after spending all day in the ER.”

Me: “Yes, I understand that she is in a hospital room on a floor with other patients—not the emergency room. And I understand that she gets her meals and medications delivered to her room, that she has a TV and phone and even had a consult with physical therapy earlier today. I know that she has been assigned a “hospital doctor” and has consulted with specialists. It certainly may seem that your mom is a patient in the hospital. But is she?”

Client’s son: “I just called case management. You’re right! She is still on something called “observation status.” They are keeping her again tonight but the social worker said she has not been admitted.”

Me: “OK. Let’s talk later after I visit your mom and speak with her doctor.”

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R.S. fell in front of her home. She can’t remember if she tripped over something or if she just collapsed. In fact, she does not remember falling at all. Now in the hospital, she was told that a neighbor found her, called 911, and an ambulance brought her to the emergency room.

As a geriatric care manager one of my roles is to advocate for my clients in the hospital. After speaking with her hospitalist, we learned that R.S. fractured her hip and several ribs and that she is suffering from a severe urinary tract infection. They are not sure if she needs surgery for her hip or if they are just going to set it. She also needs IV antibiotics for the infection.

The first question I asked her doctor was whether she was being treated as an outpatient or an inpatient. Her doctor hesitated a moment and then she admitted that yes, in fact, R.S. was still on “observation status.”

So why does this matter and why is it important to ask this question as soon as possible? Shouldn’t the hospital have an obligation to tell me?

To answer the second question first, the hospital does in fact have a responsibility to inform the patient if they are on “observation.” This is called the Medicare Outpatient Observation Notice or “MOON” and must be presented to the patient or his/her representative no later than 36 hours of starting to receive observation services at the hospital. The presenter is supposed to be able to orally explain the form and answer questions

It is important to understand, however, that even if the Medicare beneficiary refuses to sign the notice the hospital staff person just needs to document that the form was provided. I say “hospital staff” because there is no requirement that the form be presented by a doctor or social worker which would make the most sense. Technically, someone from dietary or even a security guard could present the form.

What happens if a person disagrees with their status or if the form is never presented as required? Nothing as far as the patient is concerned (although there could be financial consequences to the hospital if they are audited by Medicare). To be clear, there are no appeal rights for the patient if they do not receive the MOON nor if they disagree with their patient status.

So what does this all mean to Medicare beneficiaries and how can they protect themselves? Stay tuned for my next article where I discuss the financial and care-related implications for R.S. had she remained on observation status during her hospital stay.

Do I Really Need a Health Care Power of Attorney?

By Lisa Bayer, J.D., CCM

Recently, I was talking to a friend of mine who told me that her mom’s attorney is pushing her mom to appoint a health care power of attorney as she was just diagnosed with mild or “early stage” Alzheimer’s Disease. My friend wanted to know if the attorney was trying to drum up unnecessary business for himself because her dad is alive and well and perfectly capable of taking care of her mom.

I explained to my friend that the attorney was right to encourage her mom to prepare a legal document appointing someone to act on her behalf if and when she is unable to speak for herself. This representative is often called a “health care proxy” or a “health care power of attorney.”

Using her mom’s health care directive (also known as a “living will”) as a road map, this person, in this case her dad, will know what her mom would want if she could speak for herself and will have the authority to make decisions consistent with her wishes. I explained that it is also an opportunity for her mom to appoint surrogate decision makers in case her dad is unable or unwilling to act. Since my friend is an only child and lives close by it might make sense for her mom to name her as well.

Being related does not give someone the right to make health care decisions for another adult—only the health care power of attorney document accomplishes this. In my elder care consulting practice, I have seen difficult cases that have literally torn families apart where there is no health care proxy because the alternative is to go to court to petition for guardianship. The guardianship process is time consuming, financially costly and emotionally taxing. And if the guardianship is contested, this quantifiably increases the time and expense of the litigation.

Given my friend’s mom’s diagnosis, I also explained that there could come a time—and none of us has a crystal ball—where her mom would be unable to appreciate and execute the documents. Her attorney is under a legal and ethical obligation to make sure that her mom has the capacity to sign them.

I told my friend that my suggestion would be to follow her attorney’s advice and have the documents prepared as soon as possible.