managed care

HIPAA Release as part of Estate Plan in case of Long Term Care

Posted on May 25, 2017 by Jim Koewler — No Comments ↓

Last week’s installment (May 19, 2017) discussed everyone should include a HIPAA Release as part of an estate plan in case of emergency. This week’s installment will discuss the importance of a HIPAA Release when someone needs long term care.

As mentioned last week, a HIPAA release allows a person’s health care providers to share private health information with whomever is named in the HIPAA release. Also as discussed last week, the person’s health care providers may not feel able to share such information even with the person’s Health Care Agent until the patient is unable to make decisions for himself/herself. (Remember, the Health Care Agent is the person appointed in a Health Care Power of Attorney to make health care decisions when the patient, called the Principal for purposes of signing the HIPAA Release.) Fortunately, or unfortunately, the privacy requirements also apply to long term care providers.

The applicability of the HIPAA’s privacy requirements to long term care providers is fortunate because we all should be able to keep our health information private and to expect our providers to keep it private as well. It helps us maintain our dignity (even in the face of the frequent indignities that accompany long term care.)

On the other hand, the applicability of HIPAA’s privacy requirements to long term care providers is unfortunate because it sometimes keeps concerned family members out of the loop. In fact, sometimes long term care providers use the privacy requirements to stifle pushy family members. Concerned family members can (and should) ask questions about a loved one’s care. Concerned family members should try to participate in the quarterly care conferences required for people receiving long term care.

However, when the staff gets tired of the family member’s pushiness, the staff can invoke the HIPAA privacy requirement to explain the need to stop sharing information with the family members. A member of management might apologize for the inconvenience and for the inadvertent sharing of information in the past (“until we realized our mistake.”) Nonetheless, the staff might suddenly invoke the privacy requirements to exclude the pushy family member from care conferences and maybe even day-to-day discussions of the loved one’s care and condition. The staff might even invoke the privacy requirement against a Health Care Agent if the Principal (the loved one receiving care) hasn’t been legally deemed incompetent.

The staff’s real goal might not be adherence to the privacy rules but might be extricating themselves from someone they consider a bother. It may not be fair. It may not be right. Yet, caregiving staff has a tough enough job. Shutting down someone they deem an interference might bring them a little relief. (Not everything that we like or want is fair to others.)

So, people who want their family members and or friends to be able to advocate for them in long term care should execute a broad blanket HIPAA release as part of an estate plan.

HIPAA Release as part of Estate Plan in case of Emergency

Posted on May 19, 2017 by Jim Koewler — No Comments ↓

Powers of attorney are part of a well considered estate plan. Powers of attorney, both “general” powers of attorney and health care powers of attorney, help the principal (the person who signs the powers of attorney and extends his/her authority to someone else) prepare for a time when the principal might not be able to handle his/her own affairs. The principal might have an accident of some sort leaving him/her unconscious, or the principal might suffer from dementia late in life. In any such instance, powers of attorney can put someone in the position to speak for the principal and make decisions when the principal can’t.

A comprehensive estate plan should also include a blanket HIPAA release. HIPAA, the Health Insurance Portability and Accountability Act of 1996 created the health information privacy requirements for providers of health care services. HIPAA’s privacy rules prohibit health care providers from sharing patients’ private health information with anyone whom the patient has not authorized to receive such information.

Now, the agent appointed in the principal’s health care power of attorney is generally considered to be authorized to receive the principal’s private health information when the principal is deemed not able to handle his/her own affairs. That makes sense. We wouldn’t want a health care agent making health care decisions without knowing the principal’s health care situation. That would be dangerous.

Some people believe that the health care agent doesn’t have the right to receive the principal’s private health information until the principal cannot speak for himself/herself. That situation concerns me. What if, as in my example above, the principal is unable to speak for himself/herself because of a car accident or for some other sudden reason? That principal needs health care decisions made in an emergency. Now, of course, emergency medical providers will provider the medical care necessary to deal with the emergency. However, what if the principal has some non-obvious medical condition that the emergency personnel need to know? If the agent has not been able to receive the principal’s health information, then no one might be able to warn the emergency personnel about the principal’s unusual condition.

Of course, the agent might not be available in an emergency situation because the emergency personnel will probably not be able to look for the agent (or even a health care power of attorney document) while trying to attend to the principal’s emergency. Health care professionals won’t withhold emergency treatment while looking for the health care agent. Emergencies don’t usually lend themselves to waiting for legal niceties.

In the aftermath of the emergency, though, medical providers will want permission from the principal or the health care agent to provide follow-on care. This follow-on care will not be “emergency,” but it may be pressing. Because of whatever created the need for emergency care (like a fall, an accident, or a stroke, for example,) the principal may not be able to make a decision or may not be able to communicate his/her decision on health care matters. As a result, the agent may need to make these decisions and, in some circumstances, may need to make these health care decisions quickly. When time is of the essence in a health care setting, I’d hate for the principal’s care to wait while the agent learns for the first time about the principal’s potentially complicated health conditions.

So, I prefer that the principal have thought ahead about the possibility of such an emergency. I prefer that the principal have created a broad HIPAA release to allow the sharing of health information to the agent and the successor agents named in the principal’s health care power of attorney.

In addition, the principal might want to include others that might be involved with the agent at the time the principal needs care, such as the family attorney or an elder law attorney, or a member of the clergy.

Medicare, Rehab, and “Failure to Improve”

Posted on March 13, 2017 by Jim Koewler — No Comments ↓

After a hospital stay, Medicare-covered people may need rehab to continue improving from the treatment that the hospital provided. (As discussed in the March 10, 2017 installment, the hospital stay must be at least three days and a full “admission” to the hospital.) In the past, as a way to save money, Medicare would cut off rehab for someone who wasn’t getting better (or wasn’t getting better fast enough.)

BUT, Medicare’s rules don’t allow for a cut-off of rehab for a failure to improve. Medicare got sued to stop using the “improvement” standard. A class action lawsuit was filed in 2011 in Vermont, Jimmo v. Sebelius (Kathleen Sebelius was the United States Secretary for Health and Human Services between 2009-2014.) Jimmo and the other claimants pointed out that the Medicare rules do not set restoration of the patient’s condition as the only goal of rehab. Instead, the rules specifically list the preservation of current capabilities and the prevention of further deterioration as alternate goals if restoration isn’t possible.

Now, restoration is listed in the rules as the goal of rehab when the patient is trying to recover from a malformed body part. Unfortunately, that restoration goal came to be applied to most or all rehab programs, not just to malformed limbs. Using a “failure to restore” the patient’s function test allows payment to be cut off earlier in the rehab process than would using a “preservation of current function/prevention of deterioration” test. Cutting off rehab earlier saves Medicare and its insurance affiliates save a great deal of money when rehab gets shut down early. As a result, bit by bit, most or all rehab patients came to be measured by their progress toward restoration of function, and when the patient failed to improve toward that goal, payment for rehab get cut off.

The Jimmo lawsuit forced Medicare to face its failure to follow its own rules. The Jimmo lawsuit didn’t go to trial but, instead, led to a settlement agreement that Medicare would stop improper use of the “restoration” standard and its “failure to improve” test for ending rehab payments. (The restoration goal still applies to malformed body parts.) The judge approved the settlement as a court order.

Unfortunately, years later, rehab providers and Medicare’s insurers are still applying the failure to improve standard. The Jimmo case went back to court to demand that Medicare follow the settlement agreement. (Based on the resulting court order, it appears that the judge is not happy with Medicare.) Under the new court order that adds to the original settlement agreement, Medicare must undertake an effort to educate the public that the failure to improve test does not apply.

To patients undergoing rehab, the Jimmo case is the basis to argue that rehab should not be ended. The proposed ending of rehab must come in writing with an explanation of the right to appeal. The Jimmo settlement is an argument to present in the appeal.

Unfortunately, many hearing officers are more familiar with the incorrect approach that “failure to improve” is a reason to end rehab than they are familiar with the Jimmo agreement. Appeals about the continuation of rehab may require the help of an attorney who works in Medicare or Medicaid.

Also, the Jimmo settlement does not get rid of the 100-day limit on Medicare payments for rehab. The 100 days of available rehab does not reset unless the patient can go 60 days without needing Medicare’s support for the health issue that led to rehab. If the family is concerned about the patient going 60 days without needing more medical help, the family may not wish to push the Jimmo issue too far. The family may wish to “save” some of the 100 days.

In summary, if a patient seems to be getting pushed out of rehab early and the patient or family wishes rehab to continue, argue that Medicare can’t cut off rehab for a failure to improve. Use the name “Jimmo,” so the care provider, insurer, or hearing officer can look for the agreement.

Medicare, Rehab, and Observation Status

Posted on March 9, 2017 by Jim Koewler — No Comments ↓

Rehab is expensive. No surprise there. Under the right circumstances, the person getting rehab care sees little or no cost. Under the wrong circumstances, the person getting rehab will get stuck with the entire cost.

Just to be sure we all understand, “rehab” is rehabilitation. An example of rehab is the effort to strengthen the legs after a knee replacement.

In our discussion today, rehab follows a hospitalization. Most often, rehab takes place in a nursing home or in a facility similar to a nursing home that has chosen to focus on rehab services. (There is a trend to rehab at home, relieving the insurer from the room and board cost of a care facility.)

To have Medicare or an Advantage Plan cover rehab, the patient must be admitted to a hospital for a three-day period immediately before the start of rehab. If such a hospitalization took place and the patient has Medicare, then Medicare will usually pick up the entire bill for the first 20 days of rehab and all but $165 of the costs for any additional days (up to 100.) The patient or supplemental insurance picks up the $165. If the patient has an Advantage Plan, the plan’s rules will control how the costs of rehab will be handled. (Ed. Note: The $165 amount was inserted on 3/20/2017 after receiving new information.)

Separate from rehab, hospitals have economic pressures to control who gets “admitted” to the hospital. If a Medicare-covered person is re-admitted to the hospital within 30 days, Medicare will penalize the hospital for the first hospitalization for not treating the patient’s malady adequately enough the first time that another hospitalization was needed. The penalty will be a reduction in the Medicare reimbursement for the first hospital stay.

Because the risk of this payment reduction, hospitals tend not to “admit” someone on Medicare if the hospital’s staff isn’t sure that the patient can be cured. Many chronic illnesses of older adults can’t be cured. Perhaps they can be treated, or perhaps the symptoms can be controlled, but the illness may not be curable. The lack of a cure creates a stronger likelihood of the need for more hospital care for the same person for the same medical needs. This risk of more care creates a high risk of a “readmission” for the patient. So, the hospital has a reason to look for a way to avoid admitting someone with an uncurable chronic illness or with symptoms that can’t be completely diagnosed.

Hospitals have started to use “observation status.” Observation status takes place in the hospital in a hospital bed in a hospital room and looks just like an admission to the hospital, but it’s not an admission. A person on observation is “outpatient” for billing purposes. Medicare is billed via Part B rather than Part A. Advantage Plans are billed via outpatient billing codes. But, the patient doesn’t see a difference.

If a patient goes from observation status to rehab, the rehab will NOT be covered by Medicare. Rehab in a nursing home or rehab center can cost $10,000 per month. Unfortunately, someone on observation status may not know that rehab won’t be covered by Medicare or an Advantage Plan until it’s too late.

So, a person on Medicare or an Advantage Plan who is in the hospital (or the person’s loved ones) needs to advocate for full admission to the hospital. When the patient goes into a hospital room (i.e., not in the emergency room any more,) ask if the patient is admitted or on observation status. (Just using the terminology will get the staff’s attention.) If not admitted, demand to know why. Demand to know how to get fully admitted Demand to be fully admitted. Talk to the hospital social worker. Talk to the nurses. Talk to the doctors. Talk to the patient ombudsman. Talk to anyone necessary to get a full admission. (It may not happen, but if you don’t try, it definitely won’t happen.)

Check again everyday. (Status can change at any time.)

Being an advocate isn’t fun (for most people,) but it may be necessary.

“My Care Ohio” (People on both Medicare and Medicaid) Enrollment for 2017

Posted on November 3, 2016 by Jim Koewler — No Comments ↓

This week’s blog takes another break from the ongoing discussion of the 2016 changes to Ohio Medicaid’s rules. My Care Ohio enrollment for 2017 has started, so this installment will discuss strategies to reduce the adverse impacts that My Care Ohio could possibly cause to a person’s long term care.

Ohioans on both Medicare and Medicaid were first enrolled into My Care Ohio in May, June, and July 2014. These “dual eligible” (better described as “dual covered”) Ohioans were renewed around this time in 2015 and in 2016, and Ohioans who have become covered by both Medicare and Medicaid have been added to the program as they receive that dual coverage.

My Care Ohio is a system of “managed care” for people on both Medicare and Medicaid in Ohio. It is an attempt to control the state’s costs for long term care paid from the state budget.

When the implementation of My Care Ohio started in 2014, the February 22, 2014 installment tried to provide an overview on how the My Care Ohio program was supposed to work. The February 28, 2014 installment explained how My Care Ohio is an attempt to cut costs through insurance company command and control methods rather than empowering people to choose lower cost care by making it easier to qualify for in-home care Medicaid through PASSPORT or for the Assisted Living Waiver instead of maintaining the current financial incentive to choose a nursing home, with its higher cost per person The March 7, 2014 installment described the decisions that “dual eligibles” must make when My Care Ohio comes to their county: (1) whether to accept managed care for Medicare for this first year; (2) which Managed Care Organization to join; and (3) whether to accept managed care for Medicare for years two and three. The March 13, 2014 installment outlined what to choices to make when enrolling in My Care Ohio. When all of 2014’s enrollees were placed into the My Care Ohio program, the July 4, 2014 installment described how enrollees could minimize the likelihood that needed care services would be cut by opting out of Medicare participation in My Care Ohio. After a few months of experience with My Care Ohio, the December 5, 2014 installment described how the program was cutting off long term care benefits for some people.

Now that it’s time to make enrollment decisions for My Care Ohio for 2017, I want to revisit the strategies that dual-covered Ohioans should use.

My biggest fear for people in the My Care Ohio program is that their managed care organizations (i.e., the insurance companies to which they are assigned) will reduce services that the managed care organizations/insurance companies deem unnecessary as a way to cut costs. (We’ll call the managed care organizations/insurance companies the “MCOs.”) For example, if the person is in a nursing home and is doing well, the MCO might decide that the person can go home and receive home care (with a resulting big reduction in costs.) In fact, friends of mine who work in nursing homes have described a number of such discharges triggered by MCOs. Unfortunately, without the 24 hour care that a nursing home provides, these discharged seniors are at great risk to their health and well-being. Some of them will likely die.

The best protection against unwise cuts in services is the personal doctor. My fear is that a doctor could feel pressured by the MCO that pays the doctor’s fee to comply with an MCO decision. Because the doctor gets his or her payment from the MCO, the doctor may be hesitant to question or oppose the MCO’s decision to reduce services.

To avoid MCO influence over the doctor, I urge all people in the My Care Ohio program to:

– Opt out of the Medicare portion of My Care Ohio;
– Find out which MCO works best with the care providers (other than the doctor) that you would like to use and enroll with that MCO; and
-Choose a Medicare supplement (not an Advantage Plan) from an insurer that is not one of the MCOs in the My Care Ohio program.
– If you can’t get a supplement, then get the best Advantage Plan you can find.
– If the Advantage Plan is from an insurance company that serves as a My Care Ohio MCO in your area, choose a different insurance company as your MCO.

For example, a person in Summit County (where I live) can choose between United Health Care and CareSource as his/her MCO. Then the person would sign up for a Medicare supplement, preferably with a company other than United or CareSource. (Get the supplement enrollment done before December 7.) If the person can’t get a Medicare supplement (most likely because of health issues,) then the person should look for the Advantage Plan that fits best with his/her needs. (The person should look for coverage of the prescription drugs that the person uses and participation of the person’s doctor.)

If the person got a Medicare supplement or an Advantage Plan from a company other than United or CareSource, then the person should choose an MCO (United or CareSource) whose provider lists for the My Care Ohio program is best for the person’s situation. If the person DID get a Medicare supplement or Advantage Plan from United or CareSource, then the person should choose the other company as his/her MCO if at all possible.

Then, the person should tell Ohio Medicaid that he/she chooses to OPT OUT of Medicare’s participation in My Care Ohio.

After taking these steps, the person’s doctor is paid by someone other than the MCO and would be immune (as much as possible) to perceived pressure from the MCO to acquiesce to questionable care decisions.

Remember, in this fourth year of My Care Ohio, the program assumes that Medicare will be opted into My Care Ohio. You must take steps to notify the program that you choose to opt out for Medicare.

“My Care Ohio” Enrollment for 2016

Posted on November 5, 2015 by Jim Koewler — No Comments ↓

My Care Ohio enrollment is back. Ohioans on both Medicare and Medicaid were first enrolled into My Care Ohio in May, June, and July 2014. These “dual eligible” (better described as “dual covered”) Ohioans were renewed around this time in 2015,and Ohioans who have become covered by both Medicare and Medicaid have been added to the program as they receive that dual coverage.

My Care Ohio is a system of “managed care” for people on both Medicare and Medicaid in the populous areas of Ohio. It is an attempt to control the state’s costs for long term care paid from the state budget.

When the implementation of My Care Ohio started in 2014, the February 22, 2014 blog post tried to provide an overview on how the My Care Ohio program was supposed to work. The February 28, 2014 blog post explained how My Care Ohio is an attempt to cut costs through insurance company command and control methods rather than empowering people to choose lower cost care by making it easier to qualify for in-home care Medicaid through PASSPORT or for the Assisted Living Waiver instead of maintaining the current financial incentive to choose a nursing home, with its higher cost per person The March 7, 2014 installment described the decisions that “dual eligibles” must make when My Care Ohio comes to their county: (1) whether to accept managed care for Medicare for this first year; (2) which Managed Care Organization to join; and (3) whether to accept managed care for Medicare for years two and three. The March 13, 2014 installment outlined what to choices to make when enrolling in My Care Ohio. When all of 2014’s enrollees were placed into the My Care Ohio program, the July 4, 2014 installment described how enrollees could minimize the likelihood that needed care services would be cut by opting out of Medicare participation in My Care Ohio.

Now that it’s time to make enrollment decisions for My Care Ohio for 2016, I want to revisit the strategies that dual-covered Ohioans should use.

My biggest fear for people in the My Care Ohio program is that their managed care organization (i.e., the insurance company to which they are assigned) will reduce services that the managed care organization/insurance company deems unnecessary as a way to cut costs. (We’ll call the managed care organization/insurance company the “MCO.”) For example, if the person is in a nursing home and is doing well, the MCO might decide that the person can go home and receive home care (with a resulting big reduction in costs.) In fact, friends of mine who work in nursing homes have described a number of such discharges triggered by MCOs. Unfortunately, without the 24 hour care that a nursing home provides, these discharged seniors are at great risk to their health and well-being. Some of them will likely die.

To avoid MCO influence over the doctor, I urge all people in the My Care Ohio program to:

– Opt out of the Medicare portion of My Care Ohio;
– Find out which MCO works best with the care providers (other than the doctor) that you would like to use and enroll with that MCO; and
-Choose a Medicare supplement (not an Advantage Plan) from an insurer that is not one of the MCOs in the My Care Ohio program.
– If you can’t get a supplement, then get the best Advantage Plan you can find, just make sure it’s not from a My Care Ohio MCO.

For example, a person who can choose between United Health Care and CareSource as their MCO (as in Summit County where I live) would look at these insurers’ provider lists for the care providers that they prefer. Then, the person would tell Ohio Medicaid that they choose to OPT OUT of Medicare’s participation in My Care Ohio. Then the person would sign up for a Medicare supplement with a company other than United or CareSource. (Get the supplement enrollment done before December 7.) After taking these steps, the person’s doctor is paid by someone other than the MCO and would be immune to perceived pressure from the MCO to acquiesce to questionable care decisions.

Remember, in this third year of My Care Ohio, the program assumes that Medicare will be opted into My Care Ohio. You must take steps to notify the program that you choose to opt out for Medicare.

“My Care Ohio” could cut off your Long Term Care Benefits

Posted on December 4, 2014 by Jim Koewler — No Comments ↓

My Care Ohio is cutting off Medicaid payments for some seniors who need long term care. Without payment, the providers can’t afford to provide long term care.

The insurance companies that “manage” care for Ohioans who are covered by both Medicare and Medicaid have started to identify people who, in the opinion of employees of the insurance company employees, are not eligible for Medicaid and then have cut off Medicaid payments for those people. To be blunt, this seems very much like the “death panels” that Republicans claimed would result from the never-adopted Clinton health plan.

For those who have not followed the My Care Ohio discussion from its start earlier this year, My Care Ohio is a system of “managed care” for people on both Medicare and Medicaid (called “dual eligible” but more accurately described as “dual covered”) in the populous areas of Ohio. It is an attempt to control the state’s costs for long term care paid from the state budget.

When the implementation of My Care Ohio started earlier this year, I tried to provide an overview on how the My Care Ohio program will work (Managed care for Ohio Medicare/Medicaid “Dual Eligibles”) on February 22, 2014. On February 28, 2014, I explained how My Care Ohio is an attempt to cut costs through insurance company command and control methods rather than empowering people to choose lower cost care by making it easier to qualify for in-home care Medicaid through PASSPORT or for the Assisted Living Waiver instead of maintaining the current financial incentive to choose a nursing home, with its higher cost per person (My Care Ohio: A Triumph of the Stick over the Carrot.) On March 7, 2014, I described the decisions that dual eligibles must make when My Care Ohio comes to their county: (1) whether to accept managed care for Medicare for this first year; (2) which Managed Care Organization to join; and (3) whether to accept managed care for Medicare for years two and three. (Your Options in “My Care Ohio,” managed care for Medicare/Medicaid “Dual Eligibles”) On March 13, 2014, I outlined what to choices to make when enrolling in My Care Ohio. (What to choose in “My Care Ohio,” managed care for Medicare/Medicaid “Dual Eligibles”.)

When all of 2014’s enrollees were placed into the My Care Ohio program, I described how enrollees could minimize the likelihood that needed care services would be cut by opting out of Medicare participation in My Care Ohio (Keep your doctor separate from your Managed Care Organization in the “My Care Ohio” program) in my July 4, 2014 post. On November 13, 2014, I reiterated my suggestions about My Care Ohio enrollment with the opening of the renewal period for next year. (“My Care Ohio” Enrollment for 2015)

As it happens, just as we muddle through the 2015 enrollment period, we also get feedback from long term care service providers about the treatment of their clients/patients at the hands of the My Care Ohio insurance companies. That feedback is not good news for Ohio’s dual-covered seniors. The insurers are looking for people whom they can cut off from coverage using the opinions of insurance company doctors to justify their decisions.

These people would not have been covered by Medicaid in the first place if their own doctor had not determined that long term care was necessary. So, for these people under insurance company scrutiny, we have a repeated difference of opinions between doctors. It seems, however, that only the opinion of the insurance company doctor matters.

My biggest fear for people in the My Care Ohio program is that their managed care organization (i.e., the insurance company to which they are assigned, whom we will call an “MCO”) will reduce services (in order to cut costs) that the managed care organization/insurance company deems unnecessary. For example, if the person is in a nursing home and is doing well, the MCO might decide that the person can go home and receive home care (with a resulting big reduction in costs.) Sadly, my biggest fear seems to have come to pass.

These MCOs are quick to tell the people whom they de-fund that the insurance company hasn’t cut off their long term care. If the long term care stops, that’s the decision of the care provider (nursing home, assisted living facility, or home-care provider, etc.) That, however, is a disingenuous story. The real story should be that the insurer is cutting off payments to the provider and the provider is not in a position to provide long term care for free.

Now, this process is not the insurers’/MCOs’ fault (not all their fault anyway.) This is a state of Ohio decision to cut costs by cutting off care. An MCO’s job is to be the actual “hatchet man.”

So, if you or a loved one is dual covered (both Medicaid and Medicare) in Ohio, protect against service cuts. The best protection against unwise cuts in services is keeping your personal doctor and keeping your doctor away from undue influence by the MCO. To avoid MCO influence over the doctor, I urge all people in the My Care Ohio program to:

Opt out of the Medicare portion of My Care Ohio;
Find out which MCO works best with the care providers (other than the doctor) that you would like to use and enroll with that MCO; and
Choose a Medicare supplement (not an Advantage Plan) from an insurer that is not one of the MCOs in the My Care Ohio program.
If you can’t get a supplement, then get the best Advantage Plan you can find, just make sure it’s not from a My Care Ohio MCO.

Remember, in this second year of My Care Ohio, the program assumes that Medicare will be opted into My Care Ohio. You must take steps to notify the program that you choose to opt out for Medicare.

For more information, visit Jim’s website.

Jim Koewler’s mission is
“Protecting Seniors and People with Special Needs.”

For help with long term care or with planning for someone with special needs,
call Jim, or contact him through his website.

“My Care Ohio” Enrollment for 2015

Posted on November 13, 2014 by Jim Koewler — No Comments ↓

My Care Ohio enrollment is back. Ohioans on both Medicare and Medicaid were first enrolled into My Care Ohio in May, June, and July 2014. Now, it’s time to enroll for 2015.

My Care Ohio is a system of “managed care” for people on both Medicare and Medicaid (called “dual eligible” but more accurately described as “dual covered”) in the populous areas of Ohio. It is an attempt to control the state’s costs for long term care paid from the state budget.

Now that it’s time to make enrollment decisions for My Care Ohio for 2015, I want to revisit the strategies that dual covered Ohioans should use.

As I’ve written before, my biggest fear for people in the My Care Ohio program is that their managed care organization (i.e., the insurance company to which they are assigned) will reduce services (in order to cut costs) that the managed care organization/insurance company deems unnecessary. (We’ll call the managed care organization/insurance company the “MCO.”) For example, if the person is in a nursing home and is doing well, the MCO might decide that the person can go home and receive home care (with a resulting big reduction in costs.) In fact, friends of mine who work in nursing homes have described a number of such discharges triggered by MCOs. Unfortunately, without the 24 hour care that a nursing home provides, these discharged seniors are at great risk to their health and well-being. Some of them will likely die.

To avoid MCO influence over the doctor, I urge all people in the My Care Ohio program to:

Opt out of the Medicare portion of My Care Ohio;
Find out which MCO works best with the care providers (other than the doctor) that you would like to use and enroll with that MCO; and
Choose a Medicare supplement (not an Advantage Plan) from an insurer that is not one of the MCOs in the My Care Ohio program.

Remember, in this second year of My Care Ohio, the program assumes that Medicare will be opted into My Care Ohio. You must take steps to notify the program that you choose to opt out for Medicare.

For more information, visit Jim’s website.

Jim Koewler’s mission is
“Protecting Seniors and People with Special Needs.”

For help with long term care or with planning for someone with special needs,
call Jim, or contact him through his website.

Keep your doctor separate from your Managed Care Organization in the “My Care Ohio” program

Posted on July 3, 2014 by Jim Koewler — No Comments ↓

In my prior four posts on My Care Ohio, I’ve described the new (in Ohio) program for people on both Medicare and Medicaid (people called “dual eligibles.”) On February 21, 2014, I tried to provide an overview on how the My Care Ohio program will work (Managed care for Ohio Medicare/Medicaid “Dual Eligibles”.) On February 28, 2014, I explained how My Care Ohio is an attempt to cut costs through insurance company command and control methods rather than empowering people to choose lower cost care by making it easier to qualify for in-home care Medicaid through PASSPORT or for the Assisted Living Waiver instead of maintaining the current financial incentive to choose a nursing home, with its higher cost per person (My Care Ohio: A Triumph of the Stick over the Carrot.) On March 7, 2014, I described the decisions that dual eligibles must make when My Care Ohio comes to their county: (1) whether to accept managed care for Medicare for this first year; (2) which Managed Care Organization to join; and (3) whether to accept managed care for Medicare for years two and three. (Your Options in “My Care Ohio,” managed care for Medicare/Medicaid “Dual Eligibles”) On March 13, 2014, I outlined what to choices to make when enrolling in My Care Ohio. (What to choose in “My Care Ohio,” managed care for Medicare/Medicaid “Dual Eligibles”) Now that My Care Ohio has actually started in all of the counties to be included (in the three-year pilot program, anyway,) I want to revisit these issues, revise one of my suggestions, and highlight what I consider to be the most important suggestion. (I plan to resume the series on how to buy long term care insurance wisely next week.)

My biggest fear for people in the My Care Ohio program is that their managed care organization (i.e., the insurance company to which they are assigned) will reduce services (in order to cut costs) that the managed care organization/insurance company deems unnecessary. (For the sake of brevity, let’s call the managed care organization/insurance company the “MCO.”) For example, if the person is in a nursing home and is doing well, the MCO might decide that the person can go home and receive home care (with a resulting big reduction in costs.) If the person did well in a nursing home because of the 24 hour supervision, sending them home would be a mistake. However, I fear the cost-cutting motive of the MCO’s management and fear that some people will be sent home that should not move home.

The best protection against unwise cuts in services is the person’s doctor. If, though, the person’s doctor gets his or her payment from the MCO, the doctor may be hesitant to question or oppose the MCO’s decision to reduce services. To avoid MCO influence over the doctor, I urge all people in the My Care Ohio program to:

Opt out of the Medicare portion of My Care Ohio; and
Choose an MCO different than the insurance company through which they have their Medicare supplement or advantage plan.

For example, a person who has United Health Care for a Medicare supplement should make sure NOT to include Medicare in their My Care Ohio program and also make sure NOT to choose United Health Care for their My Care Ohio MCO. That way, the doctor is paid by someone other than the MCO and would be immune to perceived pressure from the MCO to acquiesce to questionable care decisions.

It’s not too late to change MCOs. Every My Care Ohio participant has 90 after coverage starts to change MCOs and possibly to opt out of Medicare coverage. My Care Ohio started on May 1 for the first group (Cuyahoga, Geauga, Lake, Lorain, and Medina counties,) so people in those counties have until July 29 (assuming I counted 90 days correctly) to switch. (The other groups started in June and July, so their 90 day period to make changes still has lots of time.)

I also withdraw my earlier suggestion not to renew your Medicare supplement or advantage plan for next year. After watching the first weeks of My Care Ohio, I feel that the separation of the doctor from My Care Ohio in the way suggested above is sufficient. Withdrawing completely from supplements and advantage plans would accomplish no more toward this goal and would add more expenses to people’s annual health costs.

For more information, visit Jim’s website.

Jim Koewler’s mission is
“Protecting Seniors and People with Special Needs.”

For help with long term care or with planning for someone with special needs,
call Jim, or contact him through his website.

What to choose in “My Care Ohio,” managed care for Medicare/Medicaid “Dual Eligibles”

Posted on March 13, 2014 by Jim Koewler — No Comments ↓

In my prior three posts, I’ve discussed the coming My Care Ohio pilot program for people on both Medicare and Medicaid (people called “dual eligibles.”) On February 21, I tried to provide an overview on how the My Care Ohio program will work (Managed care for Ohio Medicare/Medicaid “Dual Eligibles”.) On February 28, I explained how My Care Ohio is an attempt to cut costs through insurance company command and control methods rather than empowering people to choose lower cost care by making it easier to qualify for in-home care Medicaid through PASSPORT or for the Assisted Living Waiver instead of maintaining the current financial incentive to choose a nursing home, with its higher cost per person (My Care Ohio: A Triumph of the Stick over the Carrot.) On March 7, I described the decisions that dual eligibles must make when My Care Ohio comes to their county: (1) whether to accept managed care for Medicare for this first year; (2) which Managed Care Organization to join; and (3) whether to accept managed care for Medicare for years two and three. (Your Options in “My Care Ohio,” managed care for Medicare/Medicaid “Dual Eligibles”)

When deciding which options to choose among those questions, dual eligibles should consider a number of factors:

My Care Ohio is a pilot program. The dual eligibles that participate are essentially “guinea pigs.” Sorry.

My Care Ohio gives control over treatment decisions to an insurance company as a managed care organization. The insurance companies will be paid a fixed amount per person under their supervision. Treatments approved cut into the insurance company’s profit.

Medicare is the “big dog.” No matter which service providers may be on (or, more importantly, off) a Medicaid MCO’s approved list, if a dual eligible can use the service provider with his or her Medicare coverage, Medicaid (even managed care Medicaid) has to go along. (Note: Many long term care services may not fall under Medicare at all (like in-home non-skilled care.) Medicaid will have full control over those services and providers.)

My Care Ohio will probably result in a smaller number of providers staying on any one insurer’s approved list. At the same time (and unrelated,) the Affordable Care Act will probably prompt insurers to reduce their approved list of providers. So, reliance on a particular insurer may allow the insureds fewer choices of medical service providers and possibly even fewer choices in the next year.

The marketing rules for Medicare “companion” insurance (i.e., supplements and Advantage plans,) could make information from the managed care organizations available only AFTER the deadline to choose a managed care organization.

If I were choosing for myself, with the factors described above in mind, I would try to position myself for maximum flexibility to keep (or find) providers that I like as much as I possibly could.

I suggest that dual eligibles should
(1) Let the Department of Medicaid make the initial choice of the Medicaid Managed Care Organization this year (to avoid wasting time looking for information on the MCOs when that information is limited or not even available;)
(2) After the Managed Care Organizations release their information and provider lists, use the 90-day window at the beginning of year one to determine which MCO is better and change MCOs if appropriate;
(3) Opt out of managed care for Medicare. (Remember, opting out of Medicare is the default choice for year one;)
(4) Drop (don’t renew) Medicare supplements and Advantage plans when the open enrollment period arrives later this year (Remember, for these “dual eligibles,” Medicaid can pay the co-pays and deductibles for Medicare-covered services;) and
(5) Make sure to opt out of managed care for Medicare when the annual renewal of My Care Ohio comes up. (Remember, in years two and three, opting out of Medicare requires notification to the appropriate authorities.)

Good luck!

For more information visit www.ProtectingSeniors.com

Jim Koewler’s mission is
Protecting a Senior’s Life Savings™
from the costs of long term care

For help with long term care costs, call Jim
or contact him through his website.