Medicaid

Medicaid, a health insurance program funded both by the federal and state governments (administered by the state in New York), is available for those who need comprehensive health care but have a limited income and cannot afford the high cost. In order to help your parent or other elderly member of your family get the health care he needs, whether in a skilled nursing facility or at home, it is important to plan ahead for Medicaid eligibility and to learn the rules necessary for Medicaid application so that you know what is required and how to comply.

Federal and State Guidelines

• In 2004 an individual applicant may own no more than a home, personal property, a car, resources of $3,950 plus $1,500 set aside for funeral expenses, and must have an income of no more than $659 per month. Married applicants may have resources of no more than $5,700 and a monthly income of $950. All this depends on medical needs, life insurance, other public assistance, and any other issues the state finds important.
  
  
• Your parent may be entitled to keep more money than he thinks before applying for Medicaid. He also may be able to protect some of his assets before qualifying. This entitlement and protection must be planned for well in advance, three or more years before he applies. Although your parent is allowed to keep his home while he's still alive, the state may claim anything remaining in his estate to recoup what has been spent on nursing care. Depending on your state's rules, your parent may be able to protect his home by putting it in the name one of his children or grandchildren, which would keep it out of reach of the state when he dies. He may also put some of whatever assets he has in an irrevocable trust. If you wish to help your parent protect certain assets before applying for Medicaid, contact a lawyer who specializes in Medicaid planning. If you cannot afford a lawyer, contact your state legal services or state bar association about legal aid to the elderly. In addition, check the National Academy of Elder Law Attorneys (www.naela.org) for a list of attorneys. If your parent is a member of the American Association of Retired Persons (AARP), call for a 30-minute consultation with a lawyer through the Legal Services Network (1-800-424-3410) or go online at www.aarp.org/lsn. Also use the Eldercare Locator (1-800-677-1116, www.eldercare.gov ) to locate your local area agency on aging which will refer you to legal services for the elderly in your community.
  
  
• When your parent applies for Medicaid to enter a nursing home, officials check her financial records for the past 36 months to see what gifts or transfers (to protect assets) were made. If she has made these gifts or transfers within that time, she may not qualify for Medicaid immediately. She may have to wait the number of months it would take to spend on nursing home care the amount of money she gave away. Therefore, if possible and feasible, help your parent set aside as much money as she can before entering a self-paying nursing home. If your parent has enough money for at least six months nursing home care, she will have better chance of getting accepted to the home of her choice. Then, once admitted and once she goes on Medicaid, she cannot be discharged, even if the beds set aside for Medicaid patients are full.
  
  
• In general, Medicaid recipients are covered for inpatient and outpatient hospital services, doctors and dentists, treatment for those 65 and older in psychiatric hospitals and mental health facilities, periodic diagnostic tests and screenings, lab and x-ray services, nursing home care, clinic services, in-home health care for people eligible for nursing home care, medicine, supplies, medical equipment and appliances, transportation to medical appointments, and emergency ambulance transportation to a hospital. In addition to the coverage above, New York State covers foot and eye care including glasses and dentures, speech and physical therapy, and occupational therapy. While Medicaid pays for basic home health care and medical equipment in all states, each state has its own particular regulations. For information on individual Medicaid coverage in other states like Florida for example, call 1-800-633-4227 for your state's medical assistance office.
  
  

• Contact the local or county department of social services for a Medicaid application. In Manhattan, Brooklyn, the Bronx, Queens, and Staten Island call the Human Resources Administration toll free (1-877-472-8411. In Nassau County call the Department of Social Services (516-571-4444) and in Suffolk County (631-854-9700). In Westchester County call the Department of Social Services (914-995-5000). Medicaid rules vary from state to state and it is necessary to learn what your state allows. For more information call the New York State Medicaid Hotline (1-800-541-2831) or Medicare (1-800-633-4227). Also contact the American Association for Retired Persons (1-800-424-3410, www.aarp.org) which has helpful pamphlets on Medicaid and runs a Medicare/Medicaid Assistance Project.
  
  

Medicare Supplement Insurance -- Medigap
No doubt, as a caregiver of your elderly parent or relative, you are aware of the high cost of health care. To help your parent manage these costs it could certainly be important for you to review how much she is spending on health care each year. It is also important to think about her future health care needs, what benefits may be necessary, and what the costs will be.

Although both Part A and Part B of your elderly parent's Original Medicare Insurance Plan pay a good deal of the costs of her health care, there are still gaps in the coverage that become out-of-pocket expenses. For example, should your parent need an extensive hospital stay or skilled nursing care in a facility, the Original Medicare Plan covers only up to a certain amount for a certain period of time. The rest of the cost is your parent's responsibility. Also your parent is responsible for the yearly deductible for Medicare Part B, copayments for outpatient hospital services, and excess charges between what her doctor charges and what Medicare allows if the doctor does not accept assignment. And, depending on the amount and kind of care your parent needs, there may be additional out-of-pocket expenses.

To help lower these costs and get more health insurance coverage, your parent has the option of buying Medicare Supplement Insurance, also known as Medigap. However, if your parent has a Medicare+Choice Plan (a managed care plan or private fee-for-service plan) or Medicaid, she does not need a Medigap policy. A Medigap policy applies only if your parent has the Original Medicare Insurance Plan, both Part A and Part B.With your guidance your parent can look for a policy that she can afford and that gives her the coverage she needs most.

The time to buy a Medigap policy is during the open enrollment period when the insurance company can't deny the insurance or place any conditions on the policy. The open enrollment period lasts for six months and starts on the first day of the month your parent is 65 years or older and is enrolled in Medicare Part B. Look at your parent's Medicare card which shows the dates when Medicare Part A and Part B started. If your parent is 65 years or older, add six months to the date her Part B coverage started to figure out if she is in the open enrollment period. If that date is in the future, she is still in the open enrollment period. If it is in the past, your parent has missed the open enrollment and the insurance company may use medical underwriting to decide whether or not to accept your parent's application. In this case, there is no guarantee of getting a Medigap policy. Therefore, it is a good idea to apply for Medigap as soon as your parent applies for Medicare Part B.

A Medigap policy is sold by private insurance companies. When your parent buys a Medigap policy she pays a premium to the insurance company of choice. As long as she pays the premium the policy is renewed and the coverage continues year after year. The premium is in addition to the Medicare Part B premium which also must be paid monthly. The Original Medicare Plan will pay its share of approved charges no matter what hospital or doctor your parent chooses.

There are 10 standardized Medigap policies (Plans A through J), and each plan has a different set of benefits. While every Medigap insurer offers both Plan A and Plan B, not every insurer offers all 10 plans. However, every Medigap plan must cover four basic core benefits:

• Medicare Part A coinsurance amount
  
  
• Cost of 365 extra days of hospital care during the beneficiary's lifetime after Medicare coverage ends
  
  
• Medicare Part B coinsurance or copayment amount
  
  
• The first three pints of blood each year
  
  

Medicare SELECT is a type of Medigap policy available in New York State and some other states. Medicare SELECT includes the 10 standardized plans, but the beneficiary must use specific in-network hospitals and sometimes specific doctors in order to get full coverage (except in an emergency). The Original Medicare Insurance Plan will still pay its share of approved charges no matter what hospital or doctor provides the services. The advantage of Medicare SELECT is that the policy may have lower premiums.

Plan A includes the basic benefits listed above. In addition, these plans include the following coverage:
Plan B: Medicare Part A: Inpatient hospital deductible
Plan C: Part A inpatient hospital deductible, Part A skilled-nursing-facility coinsurance, Part B deductible, foreign travel emergency, at-home recovery
Plan D: Part A inpatient hospital deductible, Part A skilled-nursing-facility coinsurance, foreign travel emergency, at-home recovery
Plan E: Part A inpatient hospital deductible, Part A skilled-nursing-facility coinsurance, foreign travel emergency, preventive care
Plan F: Part A inpatient hospital deductible, Part A skilled-nursing-facility coinsurance, Part B deductible, foreign travel emergency, Part B 100% excess charges
Plan G: Part A inpatient hospital deductible, Part A skilled-nursing-facility coinsurance, foreign travel emergency, at-home recovery, Part B 80% excess charges
Plan H: Part A inpatient hospital deductible, Part A skilled-nursing-facility coinsurance, foreign emergency travel, basic coverage for prescription drugs
Plan I: Part A inpatient hospital deductible, Part A skilled-nursing-facility coinsurance, foreign travel emergency, at-home recovery, Part B 100% excess charges, basic coverage for prescription drugs
Plan J: Part A inpatient hospital deductible, Part A skilled-nursing-facility coinsurance, Part B deductible, foreign travel emergency, at-home recovery, Part B 100% excess charges, extended coverage for prescription drugs

Plans F and J have a high-deductible option, which means the premiums cost less than low deductible plans. However, there is a $1,620 out-of-pocket expense per year before these plans begin to pay anything.

These are the 12 Medigap insurers in the New York Vicinity (the five boroughs, Nassau, Suffolk, and Westchester) and the plans they offer:

• AARP/United Health Care (1-800-523-5800). Plans A through I.
  
  
• Amalgamated Life Insurance Company (1-800-711-8916). Plans A through G. Also offers group-only Medicare SELECT plans B, C, D, F in the five boroughs, Nassau County and some areas in Suffolk County.
  
  
• American Family Life Assurance Company of Columbus (AFLAC) (1-800-366-3436). Plans A through G.
  
  
• American Progressive Life & Health Insurance Co. of NY (1-800-332-3377). Plans A, B, C, D, F, G.
  
  
• AUSA Life Insurance Co., Inc. (1-888-617-6781, www.ausalife.com). Group-only plans A through J.
  
  
• EmpireHealthChoice (Empire Blue Cross & Blue Shield) (1-800-261-5962). Plans A, B, H.
  
  
• First United American Life Insurance Co. (1-315-451-2544). Plans A, B, C, F.
  
  
• Group Health Inc. (GHI) (1-800-444-2333, www.ghi.com). Plans A, B, C, I.
  
  
• Hartford Life & Accident Insurance Co. (1-800-572-9047). Plans A, B, C, D, F.
  
  
• HealthNow New York Inc. (Blue Shield of Northeastern NY) (1-800-888-1238). Plans A, B, C, H. Only offered in the Bronx.
  
  
• Mutual of Omaha Insurance Co. (1-800-775-6000, www.mutualofomaha.com). Plans A, B, F. Also offers Medicare SELECT plans B through G in the five boroughs and Nassau County, and some areas in Suffok, Westchester, and Rockland Counties.
  
  
• State Farm Mutual Auto Insurance Co. (1-800-688-0895, www.statefarm.com). Plans A, B, C, F.
  
  

For further information on Medigap insurance contact: Medicare (1-800-633-4227, www.medicare.gov); the New York State Health Insurance Department (1-800-342-3736. www.ins.state.ny.us) for purchasing a Medigap policy; New York State Health Insurance Assistance Program (1-800-333-4114) for questions regarding a Medigap policy; and the Department of Elder Affairs of Florida State Health Insurance Assistance Program (1-800-963-5337).