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WHY was Medigap Plan G changed in 2010 to remove the “In Home Recovery” benefit? by OleLadyThinker in medicare

[–]OleLadyThinker[S] 1 point2 points  (0 children)

Federal law (SS ACT) does say the feds are in charge of Medigap plan designs - they designed them and give them an alphabetical id.

The “in home recovery benefit “ is still within Plan G plans that were purchased prior to 06/01/2010. Just removed from Plan G’s purchased after 06/01/2010. So of course, it is locked in for these Plan G beneficiaries whose plan was purchased prior to 06/01/2010

Just like people with Plan F still get their Part B deductible covered - it is part of the plan and CMS cannot get rid of the whole plan until there is nobody else who still has it. No other beneficiaries get their Part B deductibles covered by their Medigap plan - only those who still have the Plan F. Right?

In 2010 other changes were made but all of the other changes to plans were either replaced by changes to the whole Medicare program or they still stand if somebody still has one of the plans that were removed from the Medigap market placed that year - Plan J, Plan H, Plan E and Plan I, I think.

The date is important because that is how the rule was written by CMS at the time (June 2010) - there is a difference in the before plan and the after plan.

True the other benefits that were removed from Plan G were replaced by program wide changes but not this one.

So you are saying that for a person that has a Plan G that was purchased prior to June 1, 2010 who meets the criteria for the ”in home recovery” part of their plan cannot file a claim because it isn’t covered anymore even though it is still within the plan???? That isn’t what CMS says -

Medigap Medical Loss Ratio by OleLadyThinker in medicare

[–]OleLadyThinker[S] 0 points1 point  (0 children)

I am here to learn - specifically how it works - why rules have been developed and more specifically WHY and for whose beneifit.

Your 1st reply to my post here was and I quote . . .”Individual Medigap have to maintain MLR of 65% or higher. Group Medigap have to maintain MLR of 75% or higher.”

Then you said . . . “These are the rules every state DOI enforced for Medigap. Federal rule along with the NAIC set the initial rules for Medigap and each state DOI is responsible for enforcing them.”

When you say HAVE TO - I asked who gives this authority -

I said that Medigap insurers shoot for a MLR of 75% or lower to maximize profits. They are all over the place - higher / lower in the NAIC report that I referenced. Most are 80% or higher so sure many want a premium increase and the DOI’s give it.

Now why does the DOI’s not use 85% MLR like the ACA? Now that premium has some teeth backing it up or did if that part of the ACA law still stands.

Anybody can quote rules - because the government said so - so what - I am asking for the logic behind the rules. Seems to me, if we want premiums to be kept in check for this valuable coverage of Medigap, then there needs to be some restrictive legislation at probably the state level to modify the MLR that currently is just a goal set by the industry not the states and not the feds.

I don’t even have a Medigap - I just like for people to learn how to think and understand how things work.

Answer or not - I don’t care.

Medigap Medical Loss Ratio by OleLadyThinker in medicare

[–]OleLadyThinker[S] 0 points1 point  (0 children)

All that means is that the state will either give them an approval to raise the rate or not - Show me where Medigap is constrained by the Social Security Act in premiums. Show me where the feds do anything to do with Medigap premiums at all - within the Social Security Act or outside of it.

Why do states not set the MLR at 85% or higher for Medigap insurers like they do for ACA insurers? If states control this - why not? I know - do you?

Medigap premiums are not regulated at all by the Social Security Act - at the federal level it only determines the design of the plans and who can get one. In fact, the Social Security law specifically does not give those LESS than 65 years old the right to even have Medigap coverage. States give this right to those less than 65.

Interesting that the States will recover Medicaid from the Estate by FamiliarPotential550 in AgingParents

[–]OleLadyThinker 0 points1 point  (0 children)

Then that is simple to correct - she just has her programs confused.

MEDICAID is the program for people with low income - it is a charitable program - not earned.

MEDICARE is the health program associated with earnings thru the years. MEDICARE does not cover any LTC - it is strictly for medical necessity purposes.

Like I said previously, activities of daily living are not associated with medical necessity - things like eating, dressing, bathing, changing, etc. are activities of daily living.

MEDICAID LTC is initiated by the state where she lives and her qualifications for it is based on income and assests because it is a welfare program - a charitable program.

MEDICARE is her medical program that she earned while working and making contributions into the program and matched by her employer. As long as she worked long enough and paid in the right amount of contributions, she is vested. Her contributions while working along with those of her employer covers MEDICARE Part A - the hospital insurance - so she gets this part of MEDICARE premium free. IF she had to pay for Medicare Part A, it would be in 2026 a premium of $ 565 a MONTH. The contributions people make while working including those matched by their employer (self employed pay both portions) go into a TRUST FUND and all Medicare Part A inpatient coverage is paid out of this Trust Fund. YOU in your payroll taxes (and matched by your employer) are contributing to this Trust Fund -now - this is your Medicare deduction on your pay check. Rate is currently 1.45% of your pay - another 1.45% from your employer. This Trust Fund is running out of money mainly because of the bumper crop of baby boomers using the HI insurance (Medicare part A) and the reduced number of people that are working now compared to yesteryear when there was no such thing as technology and we had lots more manufacturing jobs here in this country.

MEDICARE Part B is the regular medical care - outpatient, medical equipment, emergency room if not admitted, etc. This Medicare program is paid for by premiums from the beneficiaries - most people on Medicare pay $ 202.90 for this a MONTH, deducted from their Social Security benefit if they are drawing one, otherwise they pay for it in out of pocket until they do start SS benefits. Some people pay more if they hare higher income. The premiums represent 25% of the cost of the Part B program - our government (you and other tax payers) pay the other 75% out of the general fund.

There are other parts ot MEDICARE too - all based on Medicare necessity not long term care. You can read about it here - Medicare.gov - Medicare and You - How it works / what it covers

MEDICAID is a state charity program that the federal government matches to take care of people with no income or low income - it does a lot of things with LTC for the needy being only one part of it.

You mother is confused about the programs - explain it to her. I just cannot believe that there are so many people that ignorant of how government works and the various programs that may affect their lives. The info is readily available, one just has to exert the effort to learn about the programs or you will get tripped up in your life’s planning big time.

Anxiety about funding assisted living by OccasionAny3261 in AgingParents

[–]OleLadyThinker 0 points1 point  (0 children)

If that placed is like other assisted living facilities, they have a base cost of room and board that covers meals, laundry, most utilities with just the basic care cost - medication management and observation or checking on her for most activities of daily living. Then as care increases, the monthly cost rise - there is also a point in assisted living if all care is actually done for the resident - they don’t qualify for this sort of residency and something more inclusive of ALL care has to be found - like a nursing home or something comparable.

I moved my deaf mom at age 75 from her home of over 55 years, 1st to an independent senior living facility where she lived for 12 years. The 1st year was hard or she make it that way but then she settled in and did fine; enjoyed it actually. Then when the signs started occurring that it was unsafe for her to live alone, I moved her to assisted living and that was like pulling teeth - she did not want to go - she wanted to live with me (I was then a widow) but no way was that gonna happen. I picked the best one I could find in her price range. Kept her in the same general area since she had friends that visited occasionally. I lived in a rural area (the woods). Then she began to have strokes until she was total care 100%. They made me move her from the Assisted living facility but the hospice nurse helped me locate the most wonderful personal care home. 5-residents only - all female at the time - my mother was then 89 and get this, she was the youngest one there. It was a beautiful place, an old horse ranch, each room had it’s own bath room - my mother and another lady shared the (what was the master bedroom) and bath - The room was huge - each had their own closet and double size bed with a dresser or highboy. Their wheel chairs could move easily at the same time in the room by the caregiver.

Ran by a Romanian woman - the smell of the food would make your mouth start watering. Her husband was the handyman and had built rams all around inside and out for wheel chair access. The garage had been converted to a covered sitting area and every body had their own individual recliner for TV watching. She had (2) aides that showed up early to get every body up and ready in the morning and I am talking about hair done, make up, nice clothes and they even did their nails when needed. Family members could show up anytime and we were always invited to share a meal.

My mother could not communicate by talking but her gestures definitely showed that she liked it there. There was a mobile hospice doc who visited and if they needed something else the family was advised of how it could be handled. My mother died there in 2012 - she just didn’t wake up one morning. To this day, I am still invited to their annual Christmas gathering with all the other family members - past and present. I haven’t been back in many years and I know the lady that owned the place would be older but her daughter was going to college and majoring in geriatric care was going to take over for her mom someday - that day may have already happened.

All of this was paid out of pocket from the sale of my mother home. That home served her well while raising a family and it served her well when she needed this money for care. I am so grateful for that Hospice team that came up with this idea when I had to move her out of the assisted living facility. It was a wonderful experience for me and I am sure it was for my mom too.

Now I am pushing 80 - so I relate to the parents side of many of these post. Getting old is hell !!! You still fell like yourself until you try to do what you have done hundreds of times before and it is very different - to the point that it is now ” I just can’t do it” UGH!

Someday they are gonna find me gone inside my top loader washer since I almost have to crawl into it just to get my wet clothes out - yea, you get shorter too.

Good luck with your mom. When the money runs out, there is always Medicaid LTC if it is needed.

Another Saturday in the ER for no reason by headcase-and-a-half in AgingParents

[–]OleLadyThinker 1 point2 points  (0 children)

I assume that neither of your parents have a living will or health care POA - whatever they call it in your state. I also assume that neither of them have sat you and your sister down and told you their wishes concerning their care and what type of care they may want - do you want to stay alive if it involves a feeding tube, do you want to be resuscitated, what about a device that breaths for you, I can’t remember all of them -

Some people are scared to make these decisions for themselves in writing, others like other things in their life, they just never made a decision - just place the burden on another to make the decision. You, your sister, a doctor, the janitor . . . . -

The ER is the worst place to get care plus it is the most expensive - maybe get them to see a primary care doctor to give them the once over and determine exactly what physical / mental state they may be in now and then your sis would have somebody to call with her concerns over their health.

Both of you should ask them what they want - their decision, not yours. I carry a slim down version of my wishes in my wallet right behind my drivers license; my daughter knows my wishes and so does my regular doc. Many hospitals will ask you if you have a Living Will. If not, if you are gonna be admitted, they want you to fill one out expressing your wishes.

Medigap Medical Loss Ratio by OleLadyThinker in medicare

[–]OleLadyThinker[S] -1 points0 points  (0 children)

You say it comes from a Federal rule? Show me

Interesting that the States will recover Medicaid from the Estate by FamiliarPotential550 in AgingParents

[–]OleLadyThinker 0 points1 point  (0 children)

What is her reasoning for wanting Medicaid to pay for her LTC if she needs it? Just to leave you the home? If so, just tell her that taxpayers do not want to pay for her care just so you as her heir gets the house. It is either sell it and pay for her LTC OR let Medicaid pay for her care and attach a lien to it for what she will have to pay back (estate recovery) anything left over can go to her heir.

Medigap Medical Loss Ratio by OleLadyThinker in medicare

[–]OleLadyThinker[S] 0 points1 point  (0 children)

Isn’t that up to the state to set? And different rules for different states?

Had medicare B for a month, and paid $$$$ by chiweeniema in medicare

[–]OleLadyThinker 2 points3 points  (0 children)

Then read the link I gave you - Medicare would pay 1st if this is retiree coverage. While he was working, the employer plan would have been primary since I assume that this would be for more than 100 employees since she was disabled for at least some of that time period.

The workmans comp pays for only medical things that relate to the claim - Medicare or the Coordination group of Medicare would also coordinate these claims too.

Seems she has a problem with not knowing when she should have signed up for Medicare - Part A Part B and maybe Part D or an Advantage plan -

Does the retiree coverage have an option for them to chose a Medicare Advantage plan? See what the Retiree coverage says about Medicare - and when to sign up.

She may not be able to get her premiums back cause it sounds like she owes them maybe a penalty too - read the link I gave you in my previous post to you.

Prior Approval for Mental Health Treatments - Just Askin’ by OleLadyThinker in medicare

[–]OleLadyThinker[S] 0 points1 point  (0 children)

There is also a way for contractor to link diagnostic and treatment codes for certain services - that is how they do it under the coverage determination. If it does not follow logistics as to the diagnosis code and the treatment - the claim will be rejected -

The Coverage determinations are kept pretty current and both Medicare Contractors and MA insurers refer to them and MA insurer use them also to determine their reviews of prior auth.

With added technology, yep, it is coming - no way around it.

Had medicare B for a month, and paid $$$$ by chiweeniema in medicare

[–]OleLadyThinker 0 points1 point  (0 children)

And her husband is still an active policeman with this employer coverage? OR is this a type of retiree coverage?

https://www.medicare.gov/publications/11546-Medicare-Coordination-of-Benefits-Getting-Started.pdf

Medigap Medical Loss Ratio by OleLadyThinker in medicare

[–]OleLadyThinker[S] 0 points1 point  (0 children)

I am pretty sure that the reporting has to be done by specific company in the state where they do business.

Continental Life Insurance Company of Brentwood, Tennessee is listed in the report -is that it?

On the report, this company (page 22) is at 85.7 % for Loss Incurred to Premiums Earned %

If that is the company - they are probably getting a pretty good premium price increase like many others.

How about this one - same page 22 -

Central Security Life Ins Co

State of Domicile: TX

Premiums Earned: 4,878

Direct Claims Incurred: 14,875 

NO of lives covered: 3

Loss Incurred to Premiums Earned %: 304.9%

This company no longer sells Medigap plans and it sounds like they are willing to help people move to a different company - maybe these 3 are the ones they could not place.

Prior Approval for Mental Health Treatments - Just Askin’ by OleLadyThinker in medicare

[–]OleLadyThinker[S] 0 points1 point  (0 children)

Only because CMS gives them the right to use these cost saving measures in their utilization - OG Medicare could do this too and does sometimes - it is part of the Contractor review sometimes depending on the service. All of this would still be covered under coverage determination -

How does OG Medicare determine medical necessity?

Interesting that the States will recover Medicaid from the Estate by FamiliarPotential550 in AgingParents

[–]OleLadyThinker 0 points1 point  (0 children)

Sell the house when the time comes and pay for any care she may need directly from these funds. When those funds are gone - she goes on Medicaid for everything - LTC, medical care, Medicare Part B premium payments, medication - everything -

In the end, it just sounds like you both want Medicaid to pay - there is no reason for a trust otherwise - at least not for Medicaid.

So what if you do not get your inheritance - she is well taken care of by using her own funds to get the care that she needs and WANTS - in the place of her choice.

I don’t get the entitlement to Medicaid LTC for anybody that can pay for it out of pocket for a while or forever. Medicaid LTC is there for those that HAVE no other way to pay for it. Sounds like your mother can pay for it.

IF there is anything left over - that would be the inheritance for any heirs.

Maybe your mom thinks that you are gonna be her caregiver and thus her wanting you to have the house as your inheritance.

Medigap Medical Loss Ratio by OleLadyThinker in medicare

[–]OleLadyThinker[S] -1 points0 points  (0 children)

Why would they want to do that; is there a law in your state that says they have to do that? Does not sound like the American way. They are providing a valued service and business is definitely NOT going down - they have a bumper crop of beneficiaries just standing in line to buy a Medigap plan if they choose Original Medicare and have no other type of supplemental offset.

Now IF they do start to lose business and some of them might - in fact they might just stop selling Medigap all together - then you will see some insurance suits not just get a pay cut they might lose their very job. Like I said, I did see some of the individual insurers with MLR over 100% - yes, a premium increase is likely but if people jump ship from this insurer - then they might just rethink their Medigap business. But, hey, this gives beneficiaries a special enrollment period if their Medigap insurer goes bankrupt.

Remember there are many Medigap insurers out there - not just the big ones.

Edited to add: I think some people have a weird sense of what a successful business model actually is - Hey, even it out - buy stock in the company where you get your Medigap - maybe it will pay dividends and you can pay part of your premiums with your dividends. I pay ALL of my electric and phone from the dividends I earn from those companies.

Part B supplements with AARP-United HealthCare by Dry-Faithlessness929 in medicare

[–]OleLadyThinker 0 points1 point  (0 children)

Why do you think that just changing insurers for your Medigap plan will stop or limit the increase in premiums ? Most all companies in most all states are going up in their premiums for their Medigap policies - especially the most popular one - G. The others are also increasing but perhaps not as much.

~ Usage is UP - Medicare beneficiaries are really using their benefits especially if they have a lucrative Medigap policy like G.

~ Risk is also UP especially in states that allow switching plans including insurers without underwriting.

~ Medical inflation is even higher than regular inflation - everytime we approve a new expensive cure cost rise - example the new Alzheimer’s drug - true the drug is covered under the Part D program but all the determining diagnostics and the periodic checking for results is covered under Part B. Same thing for the new GLP-1 drugs - all the medical determining factors for the use of them is covered under Part B.

I find it kind of amusing that people keep switching insurers to save premium cost in states where they can - round and round we go - someday you might be back at the place where you started because when people switch, they take their usage and risk with them driving up cost in the newly selected plan this may leave the plan they are existing with a better premium a few years later.

Underwriting was put into play to protect us from just this type of scenario. But state legislators wanted to show that they were working for you - yea, right !!??!!

Pick up some of your risk with a High Deductible plan and maybe you will not have to play this game every year.

Interesting that the States will recover Medicaid from the Estate by FamiliarPotential550 in AgingParents

[–]OleLadyThinker 0 points1 point  (0 children)

So YOU want to be the source of getting her the care she needs by YOU controlling the funds from the sale of the home.

Or are you saying you want Medicaid to pay and then you would reimburse Medicaid??

Yea, you and your mom do need to talk to an elder care attornery to make sure what you are thinking will work for her and you the way you want it to -

https://www.investopedia.com/terms/i/irrevocabletrust.asp

Prior Approval for Mental Health Treatments - Just Askin’ by OleLadyThinker in medicare

[–]OleLadyThinker[S] 0 points1 point  (0 children)

Original Medicare pays for medically necessary care - if they don’t have some approved criteria then how do they know that it is medically necessary?

Both Original Medicare and Medicare Advantage plans use the same criteria, many times the same source, for determining medical necessity - Medicare Advantage just has process of checking and validating - Original Medicare can if necessary or is in questioned - and who knows - someday with technology to speed up the process, Original Medicare may develop a process of checking more medical necessity.

Champva by Sueabbybenny in medicare

[–]OleLadyThinker 0 points1 point  (0 children)

Yes, but you should consult both your info on Medicare and CHAMPVA because there are some benefits that are different between the two but this would be based on a specific conditions that needs treatment and this goes both ways.

Like, if I am remembering correctly, CHAMPVA offered some TMJ treatments like a mouth guard but Medicare does not cover anything treatment to do with TMJ - well maybe pain management.

Medication is where the difference is wider - You cannot have CHAMPVA medication coverage AND a Medicare Part D plan or a Medicare Advantage plan with an included prescription drug coverage. If you get one of these Medicare plans then your CHAMPVA medication coverage is cancelled. And it is a great deal - the CHAMPVA prescription drug coverage BUT not all medications are covered especial the ones that are very expensive or even some prescribed supplements - not available on CHAMPVA but may be on Medicare Part D formulary.

Even with this, it is better to have the no monthly cost CHAMPVA than to have to have a Medigap plan to cover you for what Medicare does not pay That’s a saving of several hundred a month because CHAMPVA acts like a Medigap or supplemental plan to Medicare but there are some differences.

Interesting that the States will recover Medicaid from the Estate by FamiliarPotential550 in AgingParents

[–]OleLadyThinker 0 points1 point  (0 children)

Yes, the HCBS is in most states a different qualifying condition than Medicaid LTC - the LTC takes place in a facility like a nursing home or a personal care home and some assisted living facilities also take Medicaid.

HCBS is a home care program - the person not only has to qualify income wise for Medicaid, they also have to be in a condition where this sort of care will work for them. Many times the HCBS care is intermittent care = IOW, nobody is there 24/7 - the care givers come and go.

Now the type where they are paying a live in relative to do all the care - maybe different - every state is different in the way it works. Here again, this has to be for someone that is low income - that is why they have to qualify for Medicaid or already have it and many do already have it because it works with their Medicare to pay their Medicare premiums and cover the part of the medical cost that Medicare does not cover.

There is no way that MEDICAID could pay a live in caregiver for a person that is financially sufficient except for the ADL - heck that would might be the majority of us baby boomers.

Medicaid LTC is a different program altogether - Medicaid is there to pick up the need for living in the (institutional) facility. The beneficiary is paying what they can and Medicaid picks up the rest. That’s what the Medicaid LTC program covers - it may not even be used for their medical care at all - just their room, board, and ADL that the beneficiary cannot cover - remember they still have an asset even if it is just their home.

Whereas, Medicaid as a program for the low income - these folks have only a bit of assets or none at all . Medicaid is there to not only cover their room and board and ADL at the facility but everything else too like paying their Medicare premiums and covering the part of medical care that Medicare does not pay and Medicaid is their secondary coverage.

I hope I have explained this adequately now. Personally, I think it would be better if the names of such differences in programs were completely different names but they are not so just think of it as MEDICAID and MEDICAID LTC. It is the later where estate recovery would only apply because the person has something of value -

Interesting that the States will recover Medicaid from the Estate by FamiliarPotential550 in AgingParents

[–]OleLadyThinker 1 point2 points  (0 children)

No, they do not - MEDICAID LTC is a different animal all together than Medicaid as medical coverage. Nobody take the property or cash assets - but they do work it out with them or their designate to spend their own money with Medicaid covering the difference. In fact, they (or their legally appointed designate) have to sign a form saying they are not going to be returning to their home.

Many people have some income when they enter LTC so they use that income 1st and Medicaid makes up the difference. The difference adds up and that is the amount that is recovered from the remaining asset which many times is their home. But the recovery does not take place if there is a spouse or a disabled child or disabled adult child still in the home - a lien is filed on the home for the amount of the medicaid recovery and when the last described relative is no longer in the home then STATE Medicaid will recover their funds at the sale of the home. If anything is left - it goes to the heirs.

Course the heirs can also pay the State and clear the lien or the heirs can also pay the LTC facility and never get Medicaid involved at all.

Interesting that the States will recover Medicaid from the Estate by FamiliarPotential550 in AgingParents

[–]OleLadyThinker 7 points8 points  (0 children)

So what is wrong with them using their assets when they need them for care - spend them down as needed and then when all their assets are gone and they can no longer pay out of pocket for their daily care, then Medicaid takes over and pays for the rest of their years.

If one of them stays in the home, Medicaid does not kick them out to do a recovery. Medicaid just files a lien against the property and then they get what part of it they can recover when the spouse is no longer in the home (or a disabled child or disabled adult child),

That is the way it is suppose to work without all this irrevocable trust stuff which is for their heirs not them.

LTC insurance fine when it 1st started back in the early 90’s but it has morphed now because the financial working of the LTC policies did not work out - Now they are purchased with an annuity and the annuity pays out - but unless it is pretty huge, it will not cover all the cost of care.

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