Why Patient Advocacy is So Important

I Have to Leave You Now  A Survival Guide for Caregivers of Loved Ones with Alzheimer's Disease by Maria V. CilettiI Have to Leave You Now: A Survival Guide for Caregivers of Loved Ones with Alzheimer’s Disease Maria V. Ciletti

Patient Advocacy- Dealing with Insurance Benefits

Health care is expensive. It can be extremely costly when you are dealing with a long term illness like Alzheimer’s Disease. Patient advocates are responsible for making sure their loved one is receiving all the health care benefits that are available to them. Medical services as well as medications, even with insurance coverage can be very expensive. In order for the advocate to make sure their loved one is receiving all the benefits they are entitled to, the advocate will need to become familiar with the private and public agencies that provide those services.

Dealing with health insurance can be a challenge. The first thing you need to do is make sure your loved one is signed up for the program he/she are eligible for. At age sixty-five, it is mandatory that everyone sign up for Medicare. If you don’t sign up for Medicare at age sixty-five you may incur financial penalties until you do sign up. There is one exception in avoiding the penalty: if you already have credible coverage, which means health care coverage from your employer or your spouse’s employer and those employers have more than twenty employees. Here is a little more information about Medicare:

Medicare: Medicare is a federally run program for people age 65 or people who are disabled. You must sign up for Medicare at age 65 or you might incur a10% penalty for each year you haven’t signed up. There are four parts to Medicare that you will need to familiarize yourself with. They are:

Medicare Part A covers hospital inpatient services, home health, durable medical equipment and hospice visits. Medicare Part A has no premium. If you were employed during your lifetime, you already paid into the Medicare program. Medicare Part A does have a $1,216 deductible each year. ($1,260 in 2015)Days 1-60: $0 coinsurance for each benefit period ($0 in 2015)Days 61-90: $304 coinsurance per day of each benefit period ($315 in 2015)Days 91 and beyond: $608 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime) ($630 in 2015)

Medicare Part B has a premium of $104.90 per month. It covers doctor visits and other outpatient services. There is a $147.00 annual deductible to be met as well as a 20% copay after the deductible has been met. You can purchase Medigap insurance to cover both the deductible and copay. Please be advised that if you wish to purchase Medigap insurance it must be done when you sign up for Medicare at age 65. After that time you will be unable to sign up for Medigap and my need to choose a Medicare Part C plan instead is you want deductible and copay to be covered.

Medicare Part C-(Managed Care Medicare) Takes the place of your regular Medicare benefits. Part C covers everything Medicare Part’s A, B & D cover. This is your one stop policy. This coverage is provided by a commercial insurance company ( Anthem BCBS, Humana, Aetna, United Health Care, Cigna, and several other commercial insurers.) Coverage for managed care Medicare policies allow the patient to have a low flat rate copay for doctor visits and another tiered copay for specialists as well as prescription drug coverage. But, just like any other private insurance, Managed Care Medicare policy holders are also limited to which providers they can see for treatment. The one thing to make sure of is that if you pick a managed care Medicare policy for your coverage is that your current doctors and hospitals are in network with the plan. Even though some managed care Medicare policies have out- of- network benefits, many don’t. So if you see a doctor that is not in the network, you may be responsible for the entire bill with out any discounts as if you saw an in network provider. Each year members get a chance to change their Part C policy. Open enrollment for Managed Care Medicare plans is October 15- December 7th. This is a good time to re-evaluate your current plan and shop around for one that may be more suitable to your needs.

Medicare Part D is prescription drug coverage. The monthly premium for Medicare Part D is calculated from 2 years of income reported on your tax return. If you made $85,000 or less and are single or made $170,000.00 or less jointly, all you would pay for coverage would be your Part- D premium. If your annual income was higher than $85,000.00 for single/ $170,000.00 jointly, you will pay a higher premium.

Medicare is the main insurance most people over sixty-five will be dealing with. Others may include:

Public Employee Retirement Systems (PERS) takes the place of Medicare. It provides health insurance, retirement, disability and survivorship benefits to employees who have worked for the state, county, town or city. Most of theses plans are underwritten by commercial insurance companies and will require you to see health care providers with in their networks.

Medicaid is a government funded health care program for individuals as well as families of lower income who cannot afford health insurance. Medicaid can be used alone as primary insurance if you are under sixty-five and financially qualify or with Medicare as a secondary insurance to pay Medicare’s deductible and twenty percent co-insurance. Medicaid will be important when your loved one is admitted to a nursing home or other LTC facility. With the Affordable Care Act in full swing, many states have expanded their Medicaid programs, opening the doors for many more people can qualify for Medicaid coverage through the Market Place on the health care exchange at https://www.healthcare.gov/ Open enrollment ends 12/15/2014 in order to get coverage starting January 1, 2015

Private Health Insurance is insurance you buy on your own if you are under age sixty-five. There is no government link to this insurance except if you would purchase it on the government health care exchange where you may qualify for a tax subsidy based on your income. Private Health Care Insurance companies administer the benefits and set their own guidelines on premium and claim payments. When looking for a private insurance, its best to research the policy to make sure that your physicians are in the network. Some private policies have low premiums but limit the health care providers that you can see. Always consult the provider directory before signing on with an insurance company.

Tricare ( formally CHAMPUS) / CHAMP VA: While the two programs bear similarities, such as being government-backed and serving those who have served, they are in fact quite distinct from each other. Tricare is insurance for active duty and retired members of the armed forces and is managed by the state department. CHAMPVA is a health coverage program for eligible veterans’ families ran by the VA Health Administration Center.

It is not only important to make sure your loved one has the coverage they are entitled to, but that you understand the benefits and how they work. With the ACA in full swing as of January 2014 there are many benefits that are low or no cost to the patient. Many of these benefits are preventative services including annual wellness visits and wellness procedures like mammograms, annual well woman exams, and pneumonia and flu vaccines. Alzheimer’s disease not only takes a toll on the patient’s brain, it takes its toll on the patient’s body too. That’s why it’s important to keep up on preventable diseases like the flu and pneumonia and more serious conditions that can be better treated when detected early.
Here are five links that will help explain the benefits that are available:


If you have questions regarding health insurance, feel free to contact me at http://www.mariaciletti.com and I will be happy to answer your questions.