Fong Law Group

Medicare Would Cover Dental, Vision, and Hearing Under Senate Democrats' Spending Plan

The Senate Democrats' proposal for a $3.5 trillion spending plan includes expanding Medicare to provide dental, vision, and hearing benefits. The proposal is now being negotiated in Congress. 

Currently Medicare does not offer much in the way of dental, vision, and hearing benefits. Medicare Part A will cover certain emergency or necessary procedures that are received in the hospital. For example, if you are hospitalized after an accident and require jaw reconstruction, Medicare Part A will pay for the dental work required as part of that procedure. 

Medicare Part B offers very limited coverage of some vision and hearing services. For example, while Medicare Part B won’t cover routine eye exams, it does cover yearly glaucoma screenings for people at high risk and cataract surgery, among a few other limited exceptions. Part B will also cover some diagnostic hearing and balance exams if they are ordered by a doctor, but it will not cover routine hearing exams or hearing aids. There is no coverage at all for routine dental work.

Many people choose Medicare Advantage plans, which are run by private insurers, instead of traditional Medicare because it is possible to get some dental, vision, and hearing benefits in most plans. According to the Kaiser Family Foundation, 79 percent of people in Medicare Advantage plans have vision coverage, 74 percent have dental coverage, and 72 percent have hearing aid coverage. 

Under the Democrats’ proposal, Medicare beneficiaries would be able to receive dental, vision, and health benefits through traditional Medicare, making it more competitive with Medicare Advantage. The exact details of the proposal are unknown, but in a 2019 bill that passed the House, Medicare beneficiaries would have paid 20 percent of the cost for basic dental coverage and routine eye and hearing exams. Democrats want to pass the spending bill through the reconciliation process, which requires all 50 Democrats to agree to the plan. Negotiations are currently underway to craft a bill that has the support of all the Democratic senators.

For more information about the Democrats’ proposal, click here and here.

Finding the Right Hospital Bed Rental

If you are caring for a loved one at home, you may need to rent a hospital bed. Here are the ins and outs of hospital bed rentals. 

The benefit of a hospital bed is that it adjusts to allow people with limited mobility to more easily get in and out of the bed. The adjustable features include the raising and lowering the head and foot of the bed as well as changing the bed’s height. The beds usually have the option to add side rails to keep patients from falling out of bed. The following are the main types of hospital beds:

• Manual. A manual hospital bed is the cheapest type of bed. It adjusts with a hand crank, and requires a certain amount of physical strength to adjust. 
• Semi-electric. A semi-electric hospital bed uses electric controls to adjust some components (for example, raising the bed’s head and foot) and a manual crank to adjust other components (for example, the height of the bed). 
• Electric. A full electric hospital bed has all electric controls. The patient has the ability to control all the adjustable features with a remote control. 
• Special beds. There are also beds that serve special purposes. A bariatric bed is a hospital bed that is specially designed to be sturdier and more comfortable for heavier patients. A low bed is set closer to the floor to prevent falling out of bed. A Trendelenburg bed provides even more adjustable features than a regular hospital bed, including the ability to stand straight up or turn into a chair. 

Hospital beds can be rented from medical supply companies and usually cost $200 to $500 a month to rent. There are a variety of ways to pay for rentals, including: 

• Insurance. Most private insurance policies cover hospital bed rentals. You will need to check your insurance policy to see how much is covered and under what circumstances. You will likely need a doctor’s prescription in order to get coverage. 
• Medicare. Medicare covers durable medical equipment, including hospital beds. Medicare will pay 80 percent of the cost of the bed rental. In order to get coverage, you must be enrolled in Medicare Part B, have a prescription from a Medicare-enrolled physician saying that the bed is medically necessary, and rent the bed from Medicare-enrolled medical equipment supplier. Medicare will cover hospital beds with variable height functions or electric functions only if deemed medically necessary.
• Veterans benefits. Health benefits from the Veterans Administration also cover medical equipment like hospital beds. Again, a doctor must prescribe the bed as medically necessary. 

Medicaid. If you are eligible for Medicaid home care services, Medicaid may pay for a hospital bed rental. Because Medicaid is a joint federal and state-run program, the rules vary depending on the state.

Medicaid's Coverage of Nursing Home Care

For better and for worse, Medicaid is the primary method of paying for nursing home care in the United States. But navigating the Medicaid system is complicated and confusing. Here are the basics. 

Medicaid (sometimes called by other names, such as "Medi-Cal" in California, "MassHealth" in Massachusetts, and "TennCare" in Tennessee) is a joint federal-state program that provides health insurance coverage to low-income children, seniors, and people with disabilities. In addition, it covers long-term care for those who qualify. This coverage has traditionally meant care in a nursing home, although coverage of care in an assisted living facility or at home are possible (see below). 

In the absence of any other public program covering long-term care (Medicare provides only limited nursing home coverage), Medicaid has become the default nursing home insurance of the middle class. Lacking access to alternatives such as paying privately or being covered by a long-term care insurance policy, most people pay out of their own pockets for long-term care until they become eligible for Medicaid. 

Each state operates its own Medicaid system, but this system must conform to federal guidelines in order for the state to receive federal money, which pays for about half the state's Medicaid costs. (The state picks up the rest of the tab.) This complicates matters, since the Medicaid eligibility rules are somewhat different from state to state and they keep changing. To be certain of your rights, consult an elder law attorney in your state who can guide you through the complicated rules of the different programs and help you plan ahead. 

While the majority of nursing homes accept Medicaid patients, there are some that do not. Even nursing homes that accept Medicaid recipients may only have a limited number of Medicaid beds available. Nursing homes must be certified by the state in order to accept Medicaid payments. Check with the facility before applying for admittance. 

To qualify for coverage, applicants must have limited assets and income. You typically cannot have more than $2,000 in assets; the figure may be slightly higher in some states. To lower your assets, you need to spend them down by paying for things that benefit the Medicaid applicant. You cannot simply give away your resources in order to qualify for Medicaid. Income limits vary by state. In some states you can keep excess income in trust; in other states you must pay your excess income to the nursing home. 

In addition to the strict income and asset limits, you must meet level of care requirements in order to qualify for nursing home coverage. Each state sets its own level of care criteria and the criteria is not always clear. The state looks at an applicants’ functional, medical, and cognitive abilities to determine if they need care in a nursing home. You are usually determined to need long-term care if you need help with two or more “activities of daily living” (such as bathing, dressing, eating, moving, and going to the bathroom). But to need a nursing home level of care, you may also need frequent medical care, such as assistance with medication, injections, IVs, or other medical treatment. The state may also consider your cognitive abilities—i.e., whether you have the ability to make decisions on your own. 

Once you qualify for Medicaid, the program pays for all your basic expenses, but nursing home residents may be charged extra for certain amenities, like a private room, comfort items, or specially prepared food. 

In addition to nursing home care, Medicaid generally covers care in an assisted living facility as well as some home care services. Home care is typically provided through home- and community-based services "waiver" programs to individuals who need a high level of care, but who would like to remain at home. States vary widely on how to qualify and what is covered. Almost all state Medicaid programs will cover at least some assisted living costs for eligible residents.

To apply for Medicaid, contact your local Medicaid office. An elder law attorney can help you navigate the Medicaid process.

Biden Administration Eases Recommended Restrictions on Nursing Home Visits

The Centers for Medicare and Medicaid Services (CMS) has issued new guidance on whether families can visit loved ones in nursing homes. The guidance allows indoor visitation even when the resident has not been vaccinated. 

The coronavirus pandemic has hit long-term care facilities particularly hard, with more than 170,000 residents and employees dying of COVID-19. Most nursing homes have had at least some restrictions on visitors in place since the start of the pandemic in March 2020. Some nursing homes have banned all visitors, some allow visits by appointment only, and some restrict visitation to outdoors only. The absence of close contact with loved ones has been extremely difficult for both residents and their families over the past year.  

Now that millions of vaccines have been administered to nursing home residents and staff, CMS has revised its guidance on nursing home visitation. The new non-binding guidance notes that outdoor visitation is preferred, even when both the resident and visitor are fully vaccinated. However, the guidance goes on to advise that indoor visitation should be allowed regardless of the visitor’s or resident’s vaccination status in most situations. CMS recommends limiting indoor visitation in the following circumstances:

• If the resident is unvaccinated and the county’s COVID-19 positivity rate is greater than 10 percent and less than 70 percent of the residents in the facility are fully vaccinated. 
• The resident has a confirmed COVID-19 infection.
• The resident is in quarantine because of exposure to a person infected with COVID-19.

CMS also states that while physically distancing should be maintained, a fully vaccinated resident may choose to have close contact with a masked visitor who performs good hand hygiene before and after. 

If the nursing home has a resident or staff member who tests positive for COVID-19, the CMS guidance recommends that visitation be suspended until the entire facility has been tested. If the outbreak is contained, then visitation can continue, but if additional cases are found, then CMS recommends suspending visitation once again. 

While the CMS provides recommendations, each state is free to make its own visitation rules. 

To read the guidance, click here. 

For resources on visiting long-term care facilities from The National Consumer Voice for Quality Long-Term Care, click here.

Help Paying for Medicare

Medicare is not free; there are premiums and deductibles. If you don't qualify for Medicaid and can't afford a Medigap policy, you may be able to get help paying for the costs of Medicare.

There are four Medicare assistance programs, called Medicare Savings Plans:

• Qualified Medicare Beneficiary (QMB): The QMB program pays for Medicare Part A deductibles, Medicare Part B premiums and deductibles, and coinsurance and deductibles for Part A and Part B.
• Specified Low-income Medicare Beneficiary (SLMB): The SLMB program pays for Medicare Part B Premium.
• Qualifying Individual (QI-1) Program: The QI-1 program is an expansion of the SLMB program that you must apply for each year. It pays for Medicare's Part B Premium.
• Qualified Disabled and Working Individuals (QDWI) Program: The QDWI Program helps pay for Medicare's Part A premium.

To qualify for these programs, you must be eligible for Medicare Part A (even if you are not enrolled) and have limited income and resources. The income and resource requirements can vary from state to state, so check with your state before applying. In general the following limits are applied.

Program	Income Limits
QMB	Monthly income must be at or below 100 percent of the poverty level. To find the current poverty guidelines, click here.
SLMB	Monthly income must be between 100 percent and 120 percent of the poverty level. To find the current poverty guidelines, click here.
QI-1	Monthly income must be between 120 percent and 135 percent of the federal poverty level. To find the current poverty guidelines, click here.
QDWI	Monthly income must be below 200 percent of the federal poverty level.  To find the current poverty guidelines, click here.

In 2021, personal assets, including cash, bank accounts, stocks and bonds must not exceed $7,970 for an individual and $11,960 for married couples (For the QDWI program, your assets cannot exceed $4000 for an individual and $6000 for a married couple). Your house and car do not count as personal assets. Some states allow additional resources above these figures; for example, New York has no resource limits for the QI-1 Program.

To apply for one of these programs, contact your state Department of Social Services office or the equivalent agency in your state.

Congress Fixes Some, But Not All, Medicare Enrollment Problems

Tucked in the federal spending bill that passed at the end of December 2020 are some changes aimed at simplifying Medicare enrollment and addressing coverage gaps. But Congress chose not to deal with the biggest problem.

Currently, Medicare enrollment begins three months before the month of your 65th birthday and continues for three months after your birthday month (for a total of seven months). Medicare Part A has no premiums, but if you do not enroll in Medicare Part B or Medicare Part D (prescription drug coverage) during the initial enrollment period, you will face penalties (with exceptions; read on). For example, your Medicare Part B premium may go up 10 percent for each 12-month period that you could have had Medicare Part B, but did not take it.  (You can delay signing up for Part B and Part D without penalty for a number of reasons, including if you have valid coverage through an employer with 20 or more employees that you still work for, or, in the case of Part D, you have private insurance that is at least as good as Medicare’s. Check with your employer or insurer to find out whether you can safely delay enrolling.) 

In addition, if you fail to enroll during the seven-month initial enrollment period, you will have to wait for the general enrollment period, which usually runs between January 1 and March 31 of each year. If you enroll during the general enrollment period, your coverage does not start until July 1. This means that you may have to wait up to seven months before you can get Medicare coverage. And, to make matters even more confusing, the general enrollment period for Part B is different from the enrollment period for Part D and Medicare Advantage plans. 

Congress has now taken a stab at ending these coverage gaps and clearing up some of the confusion. Under the new law, starting in 2023, whether you enroll during your initial enrollment period or you enroll during the general enrollment period, Medicare coverage will begin the month after enrollment. The law also allows Medicare to make exceptions for people who delay enrollment because of an “exceptional circumstance,” such as a natural disaster. Finally, the new law directs the federal government to align the Medicare Part B, Medicare Advantage, Medicare Part D enrollment periods by 2023.

While these changes will help eliminate coverage gaps, there are still problems. As tax and retirement policy expert Howard Gleckman points out, Medicare beneficiaries often miss the initial enrollment period because they are not aware of it. An earlier version of the law would have required the Social Security Administration to send notifications to individuals who are turning 65 to alert them of their eligibility for Medicare, but that provision was dropped from the final version.

What is Long-Term Care and Who Provides It?

Long-term care is the care you need if you can’t perform daily activities on your own for an extended period of time. There are a number of different ways that long-term care can be provided. 

Most long-term care involves assisting with basic personal needs rather than providing medical care. You are usually determined to need long-term care if you need help with two or more “activities of daily living” (such as bathing, dressing, eating, and going to the bathroom). Family members usually provide long-term care to start, but as an illness escalates paid care may become necessary. 

The following are the types of long-term care:

• Home care from family member. The most basic form of long-term care is when a family member becomes the caregiver. It can involve simple tasks like buying groceries or more complicated ones like bathing and dressing. Sometimes family members can be paid for their work.
• Home care aide. Home care aides provide companionship and socialization and assist with meal preparation, housecleaning, laundry, shopping, and errands. They are also called homemaker or chore aides.
• Home health care aide. Health care aides provide personal care (bathing, grooming, etc.), assist with range-of-motion exercises, provide some medically-related care (empty colostomy bags, dress dry wounds, check blood pressure, etc.), and provide assistance with housekeeping and errands. They are often referred to as personal care assistants
• Adult day care. Adult day care allows family members to get a respite from caregiving. In general, there are three types of centers: those that focus on social interaction, those that focus on health care, and special Alzheimer's care centers.  
• Assisted living facility. Assisted living facilities are a housing option for people who can still live independently but who need some assistance. Depending on the facility, that assistance may include help with meal preparation, housekeeping, medication management, bathing, dressing, transportation and some nursing care. Residents usually live on their own, in small apartments. Despite the emphasis on independence, supportive services are available 24 hours a day in order to provide different levels of help with activities of daily living. The level of medical supervision depends on the facility.
• Nursing home. Nursing homes are the highest level of long-term care. They provide 24-hour care to residents. Staff provide help with daily activities such as feeding, dressing, and bathing along with medical care and physical, occupational, and speech therapy.

Costs for care can vary widely, from a few hundred dollars a week to pay for coverage when family members are at work to $300,000 or more a year for around-the-clock home care or care in the most expensive nursing homes, perhaps with private aides hired on the side. 

Long-term care costs, whether at home, in assisted living or in a nursing home, are paid primarily from three sources: out-of-pocket, Medicaid, and long-term care insurance. Medicare, the health insurance for people over age 65, only pays for up to 100 days of skilled nursing facility care following a hospitalization, and only for so long as the patient is deemed to need skilled care. It will also pay for skilled care at home -- in theory indefinitely, but this may take some advocacy.

Who Should Purchase Long-Term Care Insurance?

Buying long-term care insurance is one way to protect against the high cost of long-term care. However, this type of insurance may not be for everyone, so consider all your options.

Long-term care – care in a nursing home or at home -- may be paid for in four main ways: 

• Out-of-pocket. If you have sufficient resources, you can pay for your long-term care needs with money you have saved. 
• Medicare. Medicare covers short-term nursing home stays after an illness or injury that requires hospitalization. Medicare covers up to 100 days of "skilled nursing care" per illness. 
• Medicaid. If you have limited resources, Medicaid will pay for nursing home care. In order to be eligible for Medicaid benefits a nursing home resident may have no more than $2,000 in "countable" assets (it may be higher in some states). 
• Long-term care insurance. With long-term care insurance, you pay monthly premiums to buy a policy that pays your long-term care costs if you are admitted to a nursing home or need home care (depending on the policy). 

Determining whether you need long-term care insurance depends, in part, on your financial situation. The cost of a long-term care insurance policy varies considerably, depending on your age when you purchase the policy, the benefit period, and the level of benefits, among other things, but the premiums can be expensive. Therefore, if you have the resources to self-insure your long-term care and still have money left over, you likely don’t need to buy a long-term care policy. On the other hand, if you cannot afford to pay monthly long-term care premiums, you will likely be able to qualify for Medicaid. 

Another factor to consider is your family’s health history. Most nursing home stays are short-term and paid for by Medicare. A common reason for needing extended long-term care is dementia. If you know you have a family history of Alzheimer’s disease, for example, it may make more sense to buy insurance. 

Of course, we never really know what the future may bring. Long-term care insurance is like any insurance policy: we don’t know if we will ever need it. In general, long-term care insurance is something to consider if:

• you have the resources to pay the premiums, even in retirement,
• you want to preserve your estate for your heirs, and
• you don’t have enough money to self-insure.

What to Look for When Choosing a Medicare Advantage Plan

As Medicare premiums rise, a Medicare Advantage plan can seem like an attractive option. But if you are considering switching from Original Medicare to a Medicare Advantage plan, you need to know what to look for. 

Medicare Advantage plans are run by private insurers, unlike Original Medicare, which the federal government operates, although the medical providers are private. The government pays Medicare Advantage plans a fixed monthly fee to provide services to each Medicare beneficiary under their care. The plans often look attractive because they offer the same basic coverage as original Medicare plus some additional benefits and services that Original Medicare doesn't offer. 

To compare Advantage plans, go to the Medicare Plan Finder at Medicare.gov. When deciding whether a Medicare Advantage plan is right for you, the following are the main factors to consider: 

• Cost. Since Medicare Advantage plans are offered by private insurers, the cost of the plan varies depending on where you live. While Medicare Advantage plans usually have lower premiums than paying for Original Medicare plus a Medigap plan, they can have higher deductibles and co-pays in certain circumstances, so you need to take those into account when calculating the cost of each plan. Medicare Advantage plans do have a cap on out-of-pocket costs, while Original Medicare does not. Check the annual maximum out-of-pocket costs for the plan. If you have a high level of health costs, a low out-of-pocket maximum may be the best option. 
• Coverage. What coverage does the plan offer? Medicare Advantage plans must cover everything that Original Medicare covers, but some plans offer additional benefits, such as dental, hearing, and vision. Plans may require your doctor to get approval for certain procedures. If the plan administrators disagree with your physician that a procedure is medically necessary, the plan may refuse to pay for it.You will want to find out how the plan is about approving treatments, referring patients to specialists or allowing patients to remain in the hospital if they are not ready to leave. You may want to check with your doctor to find out their experience with the plan and whether the plan frequently overrules the doctor.
• Doctors. Original Medicare does not have any restrictions on which doctor you use, but Medicare Advantage plans are HMOs and PPOs, meaning that not every doctor accepts the insurance. With an HMO, if you visit a doctor outside of the network, you will likely have to pay out of pocket (except in an emergency). With a PPO, you can usually see any doctor you want, but you will pay less for an in-network doctor. You will want to check if your doctor and hospital are part of the plan’s network. The best way to do this is to call your doctor’s office to confirm. 
• Prescription drugs. Most Medicare Advantage plans include prescription drug coverage, so you should check to make sure the plan covers all the medications you take. You should also check if you need any special authorizations for any of your medications or if there any limits on the amount you can get. Other questions include whether your pharmacy is a preferred provider and whether you can get prescriptions by mail. 

Quality of care. The Medicare Plan Finder includes a rating system that measures how well the plan manages health screenings and chronic conditions as well as how many customer complaints it receives, among other things. The ratings aren’t perfect, but they can give you an idea of plan’s quality.

Medicare Premiums to Increase Slightly in 2021

Medicare premiums are set to rise a modest amount next year, but still cut into any Social Security gains. The basic monthly premium will increase $3.90, from $144.60 a month to $148.50.

The Centers for Medicare and Medicaid Services (CMS) announced the premium and other Medicare cost increases on November 6, 2020. The hike could have been much worse due to rising costs during the coronavirus pandemic, but the bipartisan budget bill passed in October capped the increase. While the majority of beneficiaries will pay the added amount, a "hold harmless" rule prevents Medicare recipients' premiums from increasing more than Social Security benefits, which are going up only 1.3 percent in 2021. This “hold harmless” provision does not apply to Medicare beneficiaries who are enrolled in Medicare but who are not yet receiving Social Security, new Medicare beneficiaries, seniors earning more than $88,000 a year, and "dual eligibles" who get both Medicare and Medicaid benefits.

Meanwhile, the Part B deductible will rise from $198 to $203 in 2021, while the Part A deductible will go up by $76, to $1,484. For beneficiaries receiving skilled care in a nursing home, Medicare's coinsurance for days 21-100 will increase from $176 to $185.50. Medicare coverage ends after day 100.  

Here are all the new Medicare payment figures:
•    Part B premium: $148.50 (was $144.60)
•    Part B deductible: $203 (was $198)
•    Part A deductible: $1,484 (was $1,408)
•    Co-payment for hospital stay days 61-90: $371/day (was $352)
•    Co-payment for hospital stay days 91 and beyond: $742/day (was $704)
•    Skilled nursing facility co-payment, days 21-100: $185.50/day (was $176)

So-called "Medigap" policies can cover some of these costs. 

Premiums for higher-income beneficiaries ($88,000 and above) are as follows: 

• Individuals with annual incomes between $88,000 and $111,000 and married couples with annual incomes between $176,000 and $222,000 will pay a monthly premium of $207.90.
• Individuals with annual incomes between $111,000 and $138,000 and married couples with annual incomes between $222,000 and $276,000 will pay a monthly premium of $297.
• Individuals with annual incomes between $138,000 and $165,000 and married couples with annual incomes between $276,000 and $330,000 will pay a monthly premium of $386.10.
• Individuals with annual incomes above $165,000 and less than $500,000 and married couples with annual incomes above $330,000 and less than $750,000 will pay a monthly premium of $475.20.
• Individuals with annual incomes above $500,000 and married couples with annual incomes above $750,000 will pay a monthly premium of $504.90.

Rates differ for beneficiaries who are married but file a separate tax return from their spouse. Those with incomes greater than $88,000 and less than $412,000 will pay a monthly premium of $475.20. Those with incomes greater than $412,000 will pay a monthly premium of $504.90.

The Social Security Administration uses the income reported two years ago to determine a Part B beneficiary's premium. So the income reported on a beneficiary's 2019 tax return is used to determine whether the beneficiary must pay a higher monthly Part B premium in 2021. Income is calculated by taking a beneficiary's adjusted gross income and adding back in some normally excluded income, such as tax-exempt interest, U.S. savings bond interest used to pay tuition, and certain income from foreign sources. This is called modified adjusted gross income (MAGI). If a beneficiary's MAGI decreased significantly in the past two years, she may request that information from more recent years be used to calculate the premium. You can also request to reverse a surcharge if your income changes.

Those who enroll in Medicare Advantage plans may have different cost-sharing arrangements. CMS estimates that the Medicare Advantage average monthly premium will decrease by 11 percent in 2021, from an average of $23.63 in 2020 to $21 in 2021.

For Medicare’s press release announcing the new premium, co-payment and deductible amounts, click here.