Medical Expenses
1. What is Medicare?
Medicare is a federal program of health insurance. To be eligible for Medicare, one must have paid into the Social Security system while he or she was employed for at least 40 quarters and be 65 years of age or must have been receiving Social Security Disability Insurance for 24 months. Medicare insurance helps pay for acute illness situations and not for long-term or custodial care. Part A Medicare is primarily hospital insurance. When a hospitalization occurs, the patient is required to pay a deductible of $912. After that, Medicare will pay for most of the patient’s expenses up until the 60th day of the hospitalization. After 60 days in the hospital, the patient is required to pay $228 per day toward expenses. Part A Medicare will also help pay for stays in skilled nursing facilities, home health care, and hospice care if the patient qualifies. There is no premium for Part A.
Part B Medicare is physician services insurance. It will help pay for medical services, durable medical equipment, diagnostic tests, X-rays, and physical and speech therapies that are considered medically necessary. After the patient pays the first $110 for Medicare-approved services, Medicare will pay 80 percent of the amount approved by Medicare for the service. The patient is responsible for the 20 percent that Medicare does not pay. Also, the patient may have to pay the difference between what the doctor billed and Medicare approved unless the doctor accepts assignments. If assignment is accepted, the physician agrees to accept as the full fee the amount Medicare approves for the service. If you enroll for Part B, you must pay a monthly premium of $78.20 for 2005. In 2003, Medicare started paying for 80 percent of the cost of a mammogram once every year and a Pap smear test once every two years.
Many private health insurance companies sell Medicare supplemental insurance that will help cover a number of the gaps in Medicare insurance. The United States Congress has regulated this field so that now all companies must offer policies with 10 levels of coverage. It is important to understand what each level of coverage does and does not include.
Read each explanation of Medicare benefits that you receive regarding every claim that is submitted. If Medicare refuses to pay for something, you have the right to appeal the decision. The first step is to go to your local Social Security office and request an appeal. Medicare will then review your appeal and send you its decision. For a Part A appeal, if the amount at issue is $100 or more, you have the right to a hearing before a United
States administrative law judge. At that hearing you can be represented by an attorney and may present evidence, including sworn testimony to support your case. If the amount at issue is $1,000 or more, you will also have the right to take your case to federal court.
For a Part B appeal, if the amount at issue is $100 or more, you have the right to a hearing before a Medicare hearing examiner. If the amount at issue is $500 or more, you have a right to a hearing before a United States administrative law judge and if the amount at issue is $1,000 or more, you have the right to take your case to federal court.
2. What is Medicaid?
There are currently a number of Medicaid programs in New Jersey, each with its own eligibility guidelines and covered services. These programs are designed to provide healthcare coverage to the poor, the disabled and the elderly. If, for example, you are unable to afford healthcare, you may be eligible for New Jersey Care that is a special Medicaid program. If you are approved for Supplemental Security Income (SSI), you are automatically entitled to receive Medicaid. There are also a number of other programs that are similar to Medicaid in that they assist in affording you access to medical care or services.
3. What is te NJ EASE (New Jersey Easy Access, Single Entry)?
This program is a New Jersey Department of Health and Senior Services initiative, in partnership with county governments, to provide a new and easy way for senior citizens and their families to learn about and obtain needed services. Through NJ EASE access points, consumers can learn about community programs providing information and assistance, outreach, care management, transportation, senior centers, volunteer opportunities, health promotion, nutrition programs, education, health insurance counseling, adult protective services, and senior employment. Seniors and their families can also obtain information about in-home services such as friendly visiting, telephone reassurance, chore services, home health care and home-delivered meals.
4. What is PAAD (Pharmaceutical Assistance to the Aged and Disabled)?
This program helps eligible New Jersey residents pay for most prescription drugs, testing materials and supplies. Eligibility requirements for PAAD are based on the resident’s income, covering insurances and marital status.
5. What is the Senior Gold Prescription Plan?
This plan provides pharmaceutical assistance to New Jersey residents whose income is too high for PAAD, but is not enough to adequately cover their prescription expenses each year.
6. What is the HAAAD program(Hearing Aid Assistance to the Aged and Disabled)?
This program provides a $100 reimbursement to eligible persons who purchase a hearing aid.
7. What is the ECO program (Enhanced Community Options)?
This program offers several care alternatives to individuals who would otherwise qualify for placement in a nursing facility. The decisions involved in providing care to an elderly loved one can be confusing and overwhelming. Through ECO, the Caregiver Assistance Program (CAP) provides in-home services to an eligible New Jersey resident that supplement the services provided by the resident’s family and friends.
8. What is the CCPED Program (Community Care Program for the Elder and Disabled)?
This program is a statewide program designed to help individuals remain in, or return to, their communities by providing a variety of support services. Eight services are available under CCPED. The services include case management, home health, homemaker, medical day care, non-emergency medical transportation, respite care, social day care and prescribed drugs.
9. What is the Lifeline (Utility Assistance Program)?
This program offers $225 to persons who meet the PAAD eligibility requirements. This includes utility customers as well as tenants whose utility bills are included in their rent. Only one tenant in a household is entitled to this assistance. You are eligible for the Lifeline benefit if you are a recipient of PAAD.
10. What is the JACC program (Jersey Assistance for Community Caregiving)?
This program provides a broad array of in-home services and supports that enable an individual who would otherwise qualify for placement in a nursing facility to remain in his or her community home. By providing a uniquely designed package of supports for the individual, JACC is intended to supplement and strengthen the capacity of caregivers, as well as to delay or prevent placement in a nursing facility. JACC serves individuals who are not eligible for Medicaid or Medicaid waiver services, and participants will share in the cost of their services. You should contact your county board of social services to determine whether or not you are eligible for any of the Medicaid programs.
An important Medicaid program is Medicaid Only. If you or a spouse have to enter a nursing home to receive custodial type care, your assets (other than your residence and various personal items which may be exempt under certain circumstances) are worth less than $2,000, and the income of the person entering the home (including Social Security) is no more than $1,737 per month for 2005, then you may be eligible for this government program, which can pay for substantially all of the cost of the nursing home. Moreover, it is possible for a married spouse who remains at home to preserve a significant portion of the assets of the couple if the other spouse is institutionalized. In 2003, the law permitted a minimum of $18,132 of such assets to be protected. And, depending upon the amount of such assets, a maximum of one-half (but not exceeding $90,660) may be preserved. In addition, in the case of married persons, it may be possible to have some of the income of the spouse in the nursing home paid to the at-home spouse, without affecting eligibility for Medicaid only.
Effective July 1, 1995, New Jersey instituted a Medically Needy Program for nursing home care. Persons who have income in excess of $1,737 per month for 2005, must be covered by the Medically Needy Program. Persons who have income of less than $1,737 per month have a choice between Medicaid Only and Medically Needy. Medically Needy does not have all of the coverage available through Medicaid Only. Medically Needy does not cover Medicare Part B premiums, chiropractic visits, in-patient hospital services and out-of-nursing-home pharmaceuticals.
When considering an application for Medicaid, one should bear in mind that the rules are fairly complicated, and that transfers of assets to third parties (such as gifts to children) in order to become eligible for the program can result in a penalty period being imposed during which payments by the state will not be made for nursing home care.
OBRA-93 (Omnibus Budget Reconciliation Act of 1993), which is federal legislation effective October 1, 1993, made significant changes to Medicaid. Transfer of assets made within 36 months of application for Medicaid are penalized. The penalty is a period of ineligibility for Medicaid, determined by dividing the value of the assets transferred by the average cost of a nursing home in New Jersey. States must apportion the period of ineligibility between spouses so that only one penalty applies. In the case of joint assets, a withdrawal by one party is considered a transfer. The new law subjects transfers of income to a period of ineligibility. Transfer penalties can be avoided by returning all of the assets that were transferred. The law made significant changes in the area of trusts. However, certain types of trusts are still permitted. The secretary of health and human services was directed to promulgate regulations concerning annuities. As of this writing, those regulations have not yet been promulgated. States are now mandated to recover payments from the estates of Medicaid recipients.
If your application for Medicaid benefits is denied, if your Medicaid eligibility is terminated, or if Medicaid refuses to pay a claim, you have a right to a fair hearing before a New Jersey administrative law judge. At that hearing you have a right to be represented by counsel and to present evidence, including testimony, to support your case. The judge makes a recommendation to Medicaid regarding your case. Then, if Medicaid still denies your claim, you have a right to appeal to the Appellate Division of the Superior Court of New Jersey. In a situation where Medicaid has advised you that it intends to discontinue the payment of benefits, you may have a right to have benefits continued until your appeal has been decided.
