The insurance industry is complex and adjusting how its products are marketed may have a negative impact on consumers. Economists swear by a free market environment as being beneficial to all who participate in it. But would a free market environment work for the insurance industry? To answer that question, a group of economists studied Medicare Advantage, where beneficiaries chose from…

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Currently, many of America’s seniors are choosing to live at home with their adult children, to save on medical costs. More and more seniors need and use Medicare supplement insurance plans to maintain their health.

Medical supplemental insurance, also know as Medigap, aims to cover holes in the original Medicare. Medigap is made up of various plans that can cover co-pay, co-insurance, and deductibles. Together, the plans will give seniors 100 percent coverage. Medical supplement plans and Medigap are not to be confused with Medicare Advantage.

Navigating Medigap’s supplemental plans, can be confusing to seniors. This is where a dedicated insurance agent can help. Insurance agents should understand the policies, what they mean, how they work, how to price them out to benefit a senior’s coverage, and when to apply for coverage and not miss out on enrollment in the plan.

Selling Medicare supplement insurance is a brilliant plan that can grow the business base exponentially, if agents choose to educate clients and potential clients. Inform clients about modifications to Medigap, before enrolling:

The Medigap insurance plan was modified adding more choices
Plan K/Plan L covers 50 percent and 75 percent, respectively, of Hospice part A co-insurance as a basic benefit

For Plans K, L and N, seniors must pay a portion of the co-insurance/co-payments of Part B, which means they receive lower premiums

If current coverage ends at 65, send your medical policy application before the enrollment period, to be provided with continuous coverage.

Being proactive when selling Medicare supplement insurance ensures a healthy business base for your agency.

The annual open enrollment (AEP) for 2017 Medicare coverage begins in October 15 and ends on December 7, 2017. During the enrollment period the following changes can be made:

Change from Medicare Advantage to Original Medicare or from Original Medicare to Medicare Advantage
Switch from one Medicare Advantage plan to another or change from one Medicare Part D prescription drug plan to another
Enroll in Medicare Part D, but a late enrollment fees may be applicable

It is important to remember that to enroll in a Medicare Advantage plan there are basic criteria that need to be met, and these criteria are:

Plan holders must not have end-stage renal disease (exceptions apply)
Plan holders must be enrolled in Medicare Part A and Part B
Plan holders must reside in the plan service area

What if the holder of the plan does not want any changes? If the holder of the plan does not want to make any changes, then there is no need to do anything, provided the current plan is going to be available in 2017. If it is not, then the plan holder will receive a non-renewal notice from the insurance carrier before the AEP. No non-renewal notice? The plan stays in place.

Even if plan holders wish to keep their current coverage it does not mean that there are no new changes coming for the year. Check to see if the current plan is still the best option and find out about any changes. Make sure to clearly understand any changes that may apply to the insurance coverage.

It can be confusing for your regular and potential clients to keep the various annual election periods (AEP) straight. For Medicare Advantage/Part C and Medicare prescription drug plans there is an annual period to sign up, disenroll or change coverage for a plan. That period is October 15 to December 7.

However, if leads you are working with during this period did not sign up for one of those plans when they were first eligible for Medicare, referred to as their initial enrollment period, the AEP is their chance to make changes. Having said that, there is an exception to that general rule of thumb if the lead qualifies for a Special Election Period. (SEP)

What changes can your new and existing Medicare customers make during the AEP?

Even though your agency has sold and serviced Medicare plans for years, and frequently works with new leads, it never hurts to have good information on hand when speaking to customers. Education is a crucial part of your job.

In general, here is what existing and new Medicare customers may do during the AEP:

• Opt out of prescription drug coverage
• Enroll in a Part D prescription drug plan
• Switch from one drug plan to another
• Switch from Original Medicare, parts A and B, to Medicare Advantage
• Switch to Original Medicare from Medicare Advantage
• Switch from one Medicare Advantage plan to another

It’s important to note that any changes made during the open enrolment period do not go into effect until January 1 of the following year and your customers need to know that information.

The disenrollment period is January 1 to February 14 every year and new customers and converted leads can make changes during that period such as, switching to Original Medicare, Part A and B from Medicare Advantage.

The rules and regulations and dates and timing of when to start and stop or switch plans is considered to be one of the most frustrating things older Americans have to deal with every year. With the right approach to customer service, a thorough understanding of your products and the necessary educational component for your customers as part of your smart marketing plan, you are bound to garner numerous conversions from leads and keep existing clients happy.

By Thomas D. Begley, Jr., CELA

This is the second in a series of articles dealing with lien resolution in personal injury cases.

Medicare Advantage and Prescription Drug Plans

Medicare Part C. commonly known as Medicare Advantage, is a Medicare substitute program operated by private health insurance companies as a managed care plan. Medicare Part D similarly provides prescription coverage to eligible beneficiaries through private insurance plans. To the extent a reimbursement right may be created under a specific MAO plan, the Part C statute itself limits any recovery from a beneficiary to the amount actually received from a third party as payment for plan-covered expenses.1

ERISA Plans

Generally, employer-sponsored benefits plans are governed by the Employee Retirement Income Security Act of 1974, commonly referred to as ERISA.2 However, certain employers and their benefits plans are not subject to ERISA. These include governmental plans;’ church plans:’ plans maintained solely for the purpose of complying with applicable Workmen’s Compensation, unemployment compensation, or disability insurance laws;5 a plan maintained outside of the UnitedStates primarily for the benefit of persons who are virtually all non-resident aliens;6 or an excess benefit plan.” ERISA preempts state law that “relates to” an ERISA governed plan;8 however, ERISA does not exempt or relieve any person from complying with any law of any state that regulates insurance, banking, or securities.9 Neither an employee benefit plan nor any trust established under such a plan shall be deemed to be an insurance company or other insurer, bank, trust company, or investment company.10 As a result of this statutory framework, any self-insured employee benefit plan regulated under ERISA enjoys federal preemption of state law, but an insurance company insuring such a plan does not. Such insurance companies are regulated by state law, including laws concerning subrogation and reimbursement.11 If an ERISA plan is insured, the insurance company is subject to state law and the plan is bound by state insurance regulations insofar as they apply to the plan’s insurer. ERISA itself is silent with respect to subrogation and reimbursement, neither requiring a welfare plan to contain a subrogation clause nor barring such a clause or otherwise regulating its content12

Federal Employee Health Benefit Act

The Federal Employee Health Benefit Act (FEHBA) provides group health insurance for federal employees.13 Although there is no statutory right of subrogation or reimbursement. FEHBA contains a preemption provision under which the terms of insurance contracts issued by its private carriers purportedly preempts state and local law.1″1 However, the Supreme Court has held that FEHBA does not provide contract insurers with a federal cause of action or federal jurisdiction in a subrogation/reimbursement claim, leaving the matter to the state courts, and it further called into question whether a FEHB plan may assert any contractual recovery right at all against a beneficiary where such claims are prohibited by state law; the Court was “not prepared to say” that a carrier’s contract with the government “would displace every condition state law places on that recovery.”15

Federal Medical Care Recovery Act

The federal statutory scheme provides several independent bases for recovery of medical costs expended on behalf of government personnel and their dependents for injury or disease not connected to their military or other government service, but the Federal Medical Care Recovery Act (FMCRA)16 establishes standards generally applicable to claims of all federal departments and agencies. Significantly, while the government may exercise its recovery rights under the statute by making claims directly against third-party tortfeasors, the statute authorizes no such claims against a beneficiary. The statute provides, inter alia, that in any case in which the United States furnishes or pays for medical or dental care and treatment under circumstances creating third-party tort liability for such expenses, the United States shall have a right to recover from the third party the reasonable value of such care and treatment.17 The United States also has an independent right to recover from the third party the total amount of pay fora member of the Uniformed Services for any period in which the member is unable to perform his or her duties as a result of the injury or disease and is not assigned to perform other military duties.18

Veterans Administration and TRICARE Claims

The Veterans’ Benefits Act19 and the Armed Forces Act20 establish the Veterans Administration and TRICARE/CHAMPUS healthcare programs, respectively. Neither the VA nor TRICARE/CHAMPUS statutes allow for a lien or reimbursement claim against a beneficiary’s personal injury recovery. The government does have a subrogation right if it chooses to pursue its own claim against a third party: however, the statutes specifically governing the programs have a very narrow definition of “third party” that does not include a tortfeasor, but is specifically limited to public and private healthcare payors.21 Moreover, applicable regulations spell out that a beneficiary only has a duty to cooperate with the government’s third-party claim, and the extent of that cooperation itself is rather limited, merely obliging a beneficiary to provide necessary information for the government’s third-party claim.22  Moreover, the government’s claim is expressly limited by both statute and regulation to the extent of liability under state tort law, so federal preemption of state liability rules does not apply.

142 U.S.C. §1395w-22(a).

229 U.S.C. §, 1003.

329 U.S.C. § 1003(b)(1).

429 U.S.C. § 1003(b)(2).

529 U.S.C. § 1003(b)(3).

629 U.S.C. § 1003(b)(4).

729 U.S.C. § 1003(b)(5).

*29 U.S.C. ^ 1144(a).

“29 U.S.C. § 1144(b)(2)(A).

,0 29 U.S.C. § 1144(b)(2)(B).

11 FMCCorp. v.Holhday,498 U.S. 52 (1990).

13 Ryan v. Federal Express Corp.. 78 F.3d 123 (3d Cir. 1996).

13 38 U.S.C.§ 1725(a)(1).

M5 C.F.R. § 890.

15 Empire UealthChoice V. McVeigh.547 U.S. 677 (2006).

16 42 U.S.C. §2651.

1742 U.S.C. §2651 (a).

18 42 U.S.C. § 2651(b).

19 38 U.S.C. § 1729.

20 10 U.S.C. §1095.

21 38 U.S.C. § 1729(i)(3)and 10 U.S.C. § 1095(h)(1).

22 32 CFR §§ 199.12 and 220.9

If you are relocating to a new home that is within your Medicare plan’s service area, you will be able to keep your plan. However, if you are relocating to a place outside of the service area of your Medicare Advantage (Part C) or Part D plan, you will have to make changes. You will also need to make changes if the new location is covered by your plan, but you have access to other plans.

The period of time during which you can make adjustments to your plan is referred to as your Special Enrollment Period (SEP). Within this time frame, you can:

• Enroll in or modify your Medicare Advantage plan;
• Enroll in or modify your Part D drug plan; or
• Cancel your current Medicare Advantage plan and return to Original Medicare.

In order to make adjustments to your Medicare Advantage plan or Part D plan, you will have to learn about your new plan options in your new location. You can obtain information about these plans by visiting the Medicare website or the Medicare Plan Finder tool. In addition, you can find out about a certain plan by calling the private company’s customer service number.  

If you are eligible to receive both Medicare and Medicaid, you will have to contact the Medicaid program in the state in which you reside to learn about your options for Medicaid benefits. Pursuant to Medicare, if you inform your Medicare Advantage plan or Part D plan prior to moving, your SEP to replace your plan with another such plan starts the month before your move and continues up to two months following your move. If you inform your Medicare Advantage plan or Part D plan following your move, your SEP to change to another plan starts the month you reveal your plan, and two additional months afterwards.

by Thomas D. Begley, Jr., CELA

Medicare Advantage and Prescription Drug Plans

Medicare Part C, commonly known as Medicare Advantage, is a Medicare substitute program operated by private health insurance companies as a managed care plan. Medicare Part D similarly provides prescription coverage to eligible beneficiaries through private insurance plans. To the extent a reimbursement right may be created under a specific MAO plan, the Part C statute itself limits any recovery from a beneficiary to the amount actually received from a third party as payment for plan-covered expenses.[1]

Veterans Administration and TRICARE Claims

The Veterans’ Benefits Act[2] and the Armed Forces Act[3] establish the Veterans Administration and TRICARE/CHAMPUS healthcare programs, respectively. Neither the VA nor TRICARE/CHAMPUS statutes allow for a lien or reimbursement claim against a beneficiary’s personal injury recovery. The government does have a subrogation right if it chooses to pursue its own claim against a third party; however, the statutes specifically governing the programs have a very narrow definition of “third party” that does not include a tortfeasor, but is specifically limited to public and private healthcare payors.[4] Moreover, applicable regulations spell out that a beneficiary only has a duty to cooperate with the government’s third-party claim, and the extent of that cooperation itself is rather limited, merely obliging a beneficiary to provide necessary information for the government’s third-party claim.[5] Moreover, the government’s claim is expressly limited by both statute and regulation to the extent of liability under state tort law, so federal preemption of state liability rules does not apply.

Welfare Liens

In New Jersey, there is a lien against real and personal property of a person who has been assisted by or received support from any municipality or county. This is true whether a person has been in a county facility or at home.[6]

[1] 42 U.S.C. § 1395w-22(a).

[2] 38 U.S.C. § 1729.

[3] 10 U.S.C. § 1095.

[4] 38 U.S.C. § 1729(i)(3) and 10 U.S.C. § 1095(h)(1).

[5] 32 CFR §§ 199.12 and 220.9.

[6] N.J.S.A. 4:4-91.

Medicare is well-known for providing health insurance for people age 65 and older. However, Medicare can also provide health coverage for younger people with disabilities, so if you have a disability, it is important to know how you may qualify for Medicare.

The first step is to apply for disability benefits through the Social Security Administration. To qualify for Social Security disability insurance (SSDI) benefits, you must not be working a substantial amount, you must have paid FICA taxes for a long enough period to qualify, and you must have a severe medical condition that prevents you from working and has lasted or is expected to last at least one year, or result in death. If you have not paid enough into the system with your taxes, then you may still be able to apply for Supplemental Security Income (SSI), if you meet the income and asset limits.

Once you have been entitled to Social Security disability benefits, or Railroad Retirement Board benefits, for 24 months, then you will automatically be enrolled in traditional Medicare (Parts A and B), as opposed to a Medicare Advantage plan (Part C). If you wish to switch to Medicare Advantage, or enroll in Medicare Part D prescription coverage, you may do so during your initial enrollment period, which starts three months before your 25th month of disability and ceases three months after your 25th month of disability. You may also make such changes during the yearly enrollment period, which is from October 15 to December 7 each year.

As noted above, after becoming entitled to SSDI benefits, there is a two-year waiting period to become eligible. However, there are two exceptions. People with amyotrophic lateral sclerosis (ALS) can get Medicare when they are entitled to receive disability benefits. For people with end-stage renal disease with kidney failure who require a kidney transplant or ongoing dialysis, Medicare coverage can start three months after your dialysis starts.

Learn more about our special needs planning and special education advocacy services at www.littmankrooks.com or www.specialneedsnewyork.com.

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Original Medicare includes Medicare Part A (hospital expenses) and Part B (other health care such as doctor’s office visits). The monthly premium for most participants is $104.90. Participants also pay “coinsurance” of 20 percent of most medical services.

Medicare Advantage, or Medicare Part C plans, are run by private insurance companies, and must offer comparable coverage to parts A and B. Some Medicare Advantage plans charge the same premium as Original Medicare, but many charge an additional premium. Most also charge coinsurance or a copay (a flat fee for a medical service), and these fees vary from plan to plan.

Original Medicare offers the widest choice of doctors and other health care providers. This may be particularly important to you if you like to travel. Original Medicare also has a lower monthly cost than most Medicare Advantage plans.

Most Medicare Advantage plans cover prescription drugs, which costs extra under Original Medicare. Medicare Advantage plans, by law, have a maximum out-of-pocket expense of $6,700 per year. This can give peace of mind, but most people’s out-of-pocket Medicare spending is far less than this amount. Some plans also offer vision, dental, assisted living and nursing home care, unlike Original Medicare.

The decision to go with Original Medicare or Medicare Advantage can only be made based on the particular terms of the Advantage plan that interests you. Because they are offered by private companies, Advantage plans vary widely in terms of their coverages, premiums, copays and coinsurance fees. Consider carefully the pros and cons of each option and consult with an expert if you need help deciding.

The elder law attorneys at Hook Law Center assist Virginia families with will preparation, trust & estate administration, guardianships and conservatorships, long-term care planning, special needs planning, veterans benefits, and more. To learn more, visit http://www.hooklawcenter.com/ or call 757-399-7506.

Medicare supplement leads, whether they are exclusive or not, require some fact checking first. For example, a fair number of lead generation companies suggest they are offering real-time leads, but in reality, they are only selling information garnered from a generic health insurance form. Anyone over 65 that fills out an online form is fair game and considered to be a lead. And while they technically are leads, they may not be leads looking for Medicare supplement quotes.

Many online lead generation companies claim they offer real-time Medicare supplement leads, and some even go as far as to claim they are exclusive leads. How does one sort through all the claims and make a determination about their veracity? And how are the leads generated?

To effectively build a thriving insurance company, working with a lead generation company can help to navigate these questions. Such a company provides leads using a dedicated Medicare supplement insurance form, which specifically asks if the individual is looking for Medicare supplements, if they are looking for Medicare Advantage or Medigap, and if they are already covered by Medicare Parts A & B. Those receiving these leads know right away that these potential customers are quite serious about buying Medicare supplements and calling them is easy with the information provided.

Another important point to consider is how the lead generation company gathers their leads. Interested parties should check to see if the company garners their Medigap, Medicare or Medicare Advantage leads the same way they generate health insurance leads. If they do blanket marketing (search and email marketing) for people wanting “health” insurance, this is an ineffective strategy that will likely generate dud leads. Health insurance is not the same thing as Medicare supplement insurance.

The most desirable tools in an agent’s arsenal are Medicare supplement leads from a lead generation company that uses a dedicated Medicare form. Anything else is a waste of time and money.

Benepath is the leading provider of exclusive medicare leads. To learn more, visit http://www.benepath.net or call 1-866-368-0377

Medicare Advantage enrollees have through February 14, 2015 to withdraw from their Medicare Advantage plan and instead receive Medicare Parts A and B through Original Medicare. During this period, recipients can also join a Prescription Drug Plan (PDP) if necessary. There are some issues that individuals should keep in mind if they would like to withdraw:

• During the Medicare Advantage Disenrollment Period (MADP), it is not possible to switch to another Medicare Advantage plan – the only option is to go to Original Medicare coverage Part A and Part B. Those who would like to switch Medicare Advantage plans may do so during Fall Open Enrollment, which runs from October through December.
• Individuals returning to Original Medicare should consider how they might manage the deductibles, coinsurance and copayments they may encounter when seeking medical care and coverage. For example, individuals seeking to purchase a Medigap policy may face higher premiums or a waiting period.
• Keep in mind, if you drop other coverage (i.e. employer or union health care coverage), you may not be able to reinstate your coverage.

To learn more about these Medicare click here: http://www.medicare.gov/

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You must know how Medicare Parts A and B work — and what they offer and do not offer — before you can sell supplement plans (Medigap plans) with confidence. It is not enough to just read about Medicare, but it is a start. You can also ask other agents who sell this type of insurance to get their real-life, real-time understanding of the original Medicare and what it offers today.

To be successful in sales, you must carry a valid insurance license in the state(s) in which you plan to do business. The vast majority of carriers want you to have Errors and Omissions insurance. You can shop around for carriers, as prices vary.

Early in your work with Medicare, you will need at least two appointments to sell products for two different insurers who offer Medicare supplement plans and Medicare Advantage. Over time, you may expand the number of carriers for which you sell, but two is a good starting point that will allow you to get used to the market and carriers. Shop around for competitive carriers that appeal to your sense of business ethics.

Commit the co-pays and benefits for each company you represent to memory. Read all of the material supplied to you and get to know how each company deals with customers. You might also want to consider a marketing organization, which will have contracts with multiple insurance carriers. These companies consolidate the various Medicare contracts in one place.

Once you have your system in place, source a lead generation company with a good reputation, good pricing and an excellent customer care department. Set your goals, ask for what you want (preferably exclusive online leads) and get to work on converting the potential customers that land in your inbox.

Benepath is the leading provider of exclusive medicare leads. To learn more, visit http://www.benepath.net or call 1-866-368-0377

First, if you are receiving Social Security benefits already, then you will be enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance) automatically. You should receive information about enrollment three months prior to your 65th birthday. You will become eligible beginning the first day of the month you turn 65. If you turn 65 on the first day of the month, then you will be enrolled beginning on the first day of the prior month.

Most people not already receiving Social Security benefits will have to enroll in Medicare through the Social Security Administration. You can enroll anytime during a seven-month period that starts three months prior to your 65th birthday. You also have the option of choosing a Medicare Advantage (Part C) private insurance plan as an alternative to Part A and Part B. If you choose a Medicare Advantage plan, it may include prescription drug coverage; otherwise, you will have to join a Medicare Prescription Drug Plan (Part D).

Finally, be sure to consider the timing and interaction of any health insurance you receive through your employer. If you are retiring at age 65 and moving into Medicare, be sure to coordinate the dates of your coverage. If you will keep working past age 65, then you will need to understand how your employer’s group health plan interacts with Medicare; it may still be necessary for you to enroll in Medicare.

The attorneys at Hook Law Center assist Virginia families with will preparation, trust & estate administration, guardianships and conservatorships, long-term care planning, special needs planning, veterans benefits, and more. To learn more, visit http://www.hooklawcenter.com/ or call 757-399-7506.

Public benefits must always be considered in the settlement of a personal injury case.  They are important for two reasons:  (1) whether there is a lien to repay the public benefits, and (2) whether the plaintiff’s continued eligibility for public benefits depends on the establishment of a self-settled special needs trust.  Common public benefits include the following:

Supplemental Security Income (SSI) 

SSI is a monthly payment from the Social Security Administration to the SSI recipient.  The maximum payment for an individual for 2014 is $721 per month.[1]  For many people this is a significant benefit.  Over a calendar year, it is $9,132.  With inflation adjustments over a five-year period it might amount to $50,000.  SSI is essentially a welfare program.  It is “means-tested,” which means that there are income and asset tests to determine eligibility.  SSI does not have a lien against a personal injury settlement, but a special needs trust is required to maintain the plaintiff’s eligibility.

Social Security Disability Income (SSDI) 

The amount of the SSDI benefit, like Social Security Retirement, is based on the amount the worker paid into the system during his working career.  This is known as a PIA.  SSDI has no lien against the personal injury settlement and a special needs trust is not required to maintain eligibility.

Medicaid 

Medicaid is a medical payment program.  It provides very broad coverage.  There are a number of variations on this program.  One is straight Medicaid.  If a person’s income is less than $972 per month, he or she is aged, blind or disabled, and has assets of less than $2,000, he or she is eligible for Medicaid.  Another variation is New Jersey Family Care.  This is an income-based program.  There is no asset test.  Medicaid has a lien against a personal injury settlement.  A special needs trust is required to preserve eligibility for regular Medicaid, but not for New Jersey Family Care.

Affordable Care Act (ACA) 

The ACA is funded with Medicaid dollars for individuals who have income less than 138% of the Federal Poverty Level.  While it is unclear from the legislation and regulations and there has been no case law, it would appear that if an individual is receiving a Medicaid subsidy under the ACA, then there would be a lien against the personal injury settlement to the extent that Medicaid dollars were paid.  There is no asset test for ACA insurance, but to the extent the assets produce income, it affects eligibility and premiums.  Generally, a special needs trust would not be required.

Medicaid Waiver 

There are a number of Medicaid Waiver Programs in New Jersey.  Typically, these programs have an income cap of $2,163 per month for 2014 and an asset test of $2,000.  Medicaid Waiver Programs typically provide home care and care in residential settings such as group homes, assisted living facilities, and nursing homes.  Medicaid Waiver Programs have liens against personal injury settlements and special needs trusts are required in order to maintain eligibility.

Medicare 

Medicare is essentially a medical insurance program.  To be eligible, an individual must be over age 65 or disabled and receiving SSDI or Railroad Retirement Disability or suffer from End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).  Coverage is very broad, but there are copayments, deductibles, and premiums.  There is a Medicare lien against a personal injury settlement, but a special needs trust is not required to preserved eligibility.

Medicare Advantage 

A Medicare Advantage Plan is essentially a Medicare HMO.  Medicare Advantage Plans must provide all of the benefits covered by Medicare and they do offer additional coverage relating to deductibles and copayments.  Clients often purchase Medicare Advantage Plans rather than stay with Traditional Medicare, so that a Medicare Supplement is not required.  Medicare Advantage has a lien against personal injury settlements and a special needs trust is not required in order to maintain Medicare Advantage.

Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps)  

SNAP provides assistance to eligible individuals and families to assist in the purchase of food.  There is an income test related to total household income.  There is also an asset test.  There is no lien against a personal injury settlement.  A special needs trust is often required to maintain benefits.

Federally-Assisted Housing 

Federally-Assisted Housing provides housing assistance, usually rental assistance, to low-income individuals and families.  There is a Regional Income limit for purposes of determining eligibility and, if an individual or family is determined to be eligible, the individual typically pays 30% of his or the family’s actual adjusted gross income as rent.  There is no lien against a personal injury settlement for federally-assisted housing.  There is no asset test, but income from assets is considered income.  A special needs trust is sometimes, but not always, required to maintain eligibility.

Temporary Assistance to Needy Families (TANF) 

The TANF program in New Jersey is called WorkFirst NJ.  The program provides temporary cash assistance and many other support services.  The program known as General Assistance is part of the WorkFirst NJ program and provides benefits to families or individuals even if they do not have children.  There is a lien against the personal injury settlement.

Therefore it is critical to obtain correct information from clients, so that liens can be satisfied, trusts can be established where necessary, and MSA accounts can be set up in appropriate cases.

Not many Americans are aware of the penalties they may face if they forgo any Medicare Part. It is best to understand these penalties before making any decisions relating to Medicare/Medigap.

Medicare used to have just two parts: A and B. It was not until later that Part C was appended to allow people to get private all-in-one plans, instead of Part A and B. Congress later brought in Part D to deal with prescription drugs. Medicare Advantage offers some plans that bundle up with drug coverage.

Part A does not come with a premium, other than the payroll tax. Parts B,C, and D have additional premiums that must be paid. Those wanting to save money often think they can do that by waiting until later before they sign on the dotted line. It does not work that way. There is an additional penalty when someone does not sign up for Parts B,C, or D after becoming eligible, unless there is other insurance acceptable to Medicare.

The penalty for part B is 10 percent for every year the person did not enroll. The Part D penalty is related to the base premium for each year and rises for every month someone on Medicare does not have drug coverage. Part C higher premiums for delaying are related to the specific Medicare Advantage Plan.

Penalty exceptions are when someone has alternative coverage that is recognized by Medicare, for instance an employer or union insurance plan with medical and prescription coverage. Be aware that the rules governing this area may vary according to whether the Medicare enrollee is working or their spouse is employed. Additionally, those who decline to enroll in Medicare because they have coverage at work, may find that coverage limited by the company refusing to cover costs that Medicare would have funded.

Medicare rules are very complex and one misstep may cost a participant a lot of money. Always check what penalties may be faced before forgoing any of the Medicare Parts.

Get a medicare supplement quote now from Benepath!

Not many Americans are aware of the penalties they may pay for forgoing any Medicare Part. It is best to understand these penalties before making any decisions relating to Medicare/Medigap.

Medicare used to have just two Parts: A and B. It was not until later that Part C was appended, which allows private all-in-one plans to replace the two. Congress later brought in Part D to deal with prescription drugs. Medicare Advantage offers some plans that bundle up with drug coverage.

Part A does not come with a premium other than the payroll tax. Parts B,C and D have additional premiums that must be paid. Those looking to save money often think to do so by waiting to sign on the dotted line. However, the program does not work that way. There is a penalty when someone does not sign up for Part B,C or D after becoming eligible (unless he or she carries other insurance acceptable to Medicare).
The penalty for Part B is 10 percent for every year the person did not enroll. The Part D penalty is related to the base premium for each year, and rises for every month someone on Medicare does not have drug coverage. The higher premiums for delaying Part C are related to the specific Medicare Advantage Plan.

When someone has alternative coverage that is recognized by Medicare — for instance, an employer or union insurance plan with medical and prescription coverage — the penalties will not apply. Be aware that the rules governing this area may vary if the Medicare enrollee is working or if their spouse is employed. Additionally, those who decline to enroll in Medicare because they have coverage at work may find that coverage limited by their company.  It is possible that they will refuse to cover costs that Medicare would have funded.

Medicare rules are very complex, and one misstep can cost a participant a lot of money. Always check what penalties you may face before forgoing any of the Medicare Parts.

Obamacare has implemented major changes in the United States’ health care system, especially in Medicare.

By Chris Berry

Obamacare mandates $716 billion in Medicare payment reductions from 2013 to 2022. These across-the-board changes in Medicare payment formulas include a number of Medicare providers, including hospitals, nursing homes, home health agencies, and hospice agencies.

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While politicians will do their best to convince you that Medicare payment reductions only influence providers and not beneficiaries, the reality is that funding cuts for Medicare services will affect those who depend on those services.

Seniors’ ability to access Medicare services will continue to wither away if Congress continues to implement Obamacare’s major reductions. Medicare Trustees project that as a result of lower Medicare payment rates, 15 percent of hospitals, skilled nursing facilities, and home health agencies will no longer be profitable by 2019, and jump to 25 percent in 2030.

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The difficulty which seniors are experiencing accessing care is certain to increase if Obamacare continues to be implemented. Medicare’s payments for health services would drop increasingly below provider’s costs. As a result, providers will not be able to sustain continuing negative margins and would be forced to withdraw from serving Medicare beneficiaries or shift a major percentage of Medicare costs to their non-Medicare, non-Medicaid payers.

Along with the providers payment reductions, Obamacare reduces payments to Medicare Advantage (MA) plans by an estimated $156 billion from 2013 to 2022. Roughly 27 percent of all Medicare beneficiaries are enrolled in MA plans. MA plans are appealing to beneficiaries because they offer more generous and comprehensive coverage than traditional Medicare by capping out-of-pocket costs and offering drug coverage.

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After Obamacare was enacted 2010, the Medicare Actuary projected that the impact of Obamacare’s cuts would be dramatic: “We estimate that in 2017, when the MA provisions will be fully phased in, enrollment in MA plans will be lower by about 50 percent (from its projected level of 14.8 million under the prior law to 7.4 million under the new law).” As a result, these enrollees would have to enroll a traditional Medicare program that was less generous and ultimately cause them to lose their current health plan and be subject to increased out-of-pocket costs.

Christopher J. Berry is a Michigan elder law attorney Dedicated to helping seniors, veterans and their families navigate the long-term care maze. To learn more visit http://www.theeldercarefirm.com/ or call 248.481.4000

If a beneficiary’s health or prescriptions for medication have changed in the past year, then it might be a good idea to compare plans. It also may be that the plan itself is what has changed: many plans have increased premiums or copayments or changed the pricing tiers for prescription medication. If an insurer moves drugs from one pricing tier to another, that can have a significant effect on one’s out-of-pocket costs.

Some insurers have up to five different tiers of prescription drug pricing, and if a medication moves from a preferred to a non-preferred or specialty drug, the patient may have to pay up to 25 percent of the cost out-of-pocket. Price differences between generic and name-brand drugs are common, but some plans also have different tiers for preferred generic and non-preferred generic drugs.

One recent change in Part D is the growth of preferred pharmacy plans. Some insurers offer low premiums and low copayments if one uses a particular chain of pharmacies. The savings can be substantial when one uses the preferred pharmacy.

One can compare plans on Medicare.gov’s Plan Finder. Entering one’s zip code and medications and clicking on “prescription drug plans” brings up the plans available to the individual. The star ratings are useful in choosing a plan, because they incorporate actual members’ reported satisfaction with the plan.

Open enrollment is also an opportunity to choose a Medicare Advantage plan, if desired. To cover hospital care (Part A) and outpatient care (Part B), Medicare offers a choice between single-payer traditional Medicare or a network plan (Part C or Medicare Advantage), in which the federal government pays for a private insurer that the patient can choose. The majority of Medicare beneficiaries choose traditional Medicare, but if one chooses Medicare Advantage, now is when one can shop around among different plans.

One potential source of confusion that Medicare beneficiaries will want to avoid is that this is also the open enrollment period for the new health insurance exchanges under the Affordable Care Act. However, the two are completely separate. The health insurance exchanges are for people who do not have health insurance, and Medicare beneficiaries do have health insurance, through Medicare. The online location to compare Medicare plans is Medicare.gov, not Healthcare.gov.

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Medicare Advantage continues to flourish despite Obamacare cuts

By Chris Berry

Amidst the dysfunction within the new Obamacare insurance marketplaces, one existing coverage program appears to be flourishing.

One of the most severe and initial criticisms of President Obama’s health care law was that it would come as a detriment to seniors. Critics contended that the law’s $700 billion in cuts to Medicare over 10 years would withhold both benefits and choices from seniors. In particular, it was feared that the $100 billion cut from Medicare Advantage, which enables seniors to acquire government-funded private insurance plans in place of traditional Medicare.

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However, four years later the program has reached new levels of popularity. Between 2010 and 2013, enrollment in the program jumped 30%.

Despite the progress, some Republicans contend that the program is in jeopardy due to Obamacare. “The chances are that soon [seniors] will open up the mail to the bad news that your Medicare Advantage … has been changed in a negative way for you because of Obamacare,” said Senator Marco Rubio recently, paying no mind to the stability of premiums, plan choices and benefits under Medicare Advantage.

(Related: Obamacare and Long-Term Care Insurance)

“So far, the concerns have not been borne out,” says Tricia Neuman, a senior vice president at the Kaiser Family Foundation who studies Medicare Advantage. “Enrollment continues to climb. Some of the forecasts have predicted that plans would pull out and people would drop out — so far it hasn’t happened.”

Medicare open enrollment begins on Oct. 15, and close to 14 million seniors who choose Medicare Advantage will discover options are improved at only a slight raise of cost that in the past. According to the U.S. Department of Health and Human Services (HHS), which oversees Medicare, the average monthly premium of Medicare Advantage will increase by only $1.54 in 2014, from 2013. Regarding benefits and cost sharing, Gretchen Jacobson, also of Kaiser, says, “We haven’t seen dramatic changes.”

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Medicare Advantage was originally chosen for cuts because the the government was spending close to 14% more per enrollee in the program than for those enrolled in standard Medicare.

While cuts on Medicare Advantage will continue until 2017, thus far, the program has not suffered.

Read more: http://nation.time.com/2013/10/14/obamacares-reviled-medicare-cuts-have-turned-out-better-than-expected/

Christopher J. Berry is an elder law attorney Dedicated to helping seniors, veterans and their families navigate the long-term care maze. To learn more visit http://www.theeldercarefirm.com/ or call 248.481.4000

Individuals with Original Medicare should expect to continue the same level of care when they move. But if you also have a Medigap policy, be sure to touch base with your insurer. Your premium may change, based on your new location. Also, if you are enrolled in Medicare SELECT, you may need to buy a supplemental policy in order to use doctors and hospitals within the correct network.

If you are enrolled in Medicare Advantage, you should check with your plan to ensure that you will still be within its service area, and switch to a new area plan, if needed. If you decide to switch to the new area Medicare Advantage plan, you may do so under the special enrollment period, and get the new plan immediately, without an extended waiting period.

You may wish to switch to Original Medicare or to the Medicare Advantage plan which covers your new location. If you do nothing, you will automatically be enrolled in Original Medicare, which may mean you will need additional coverage for prescription drugs as well as a Medigap policy.

Christopher J. Berry is a Michigan elder law attorney Dedicated to helping seniors, veterans and their families navigate the long-term care maze. To learn more visit http://www.theeldercarefirm.com/ or call 248.481.4000

The study looked at more than 6 million Medicare Advantage patients in 2009. More than 1 million of those patients received prescribed medications that are labeled “high risk,” while 5 percent received multiple high-risk prescription medications. Seniors are generally advised to avoid high-risk prescription medications and to ask for safer alternatives.

More than 100 medications are currently classified as “high-risk” for side effects when taken by seniors, while the same medications are not generally considered to have high-risk side effects for younger patients. Most notable, stated researchers, was the geographic variation found in the study: Southeastern-based patients were between 10 and 12 percent more likely to have been prescribed a high-risk medication than a patient living in the Northeast. Additionally, Caucasian seniors, female seniors and seniors who were low-income all were prescribed high-risk medications at a higher rate.

Researchers posit that many medical professionals are unaware of medications that are considered high-risk for geriatric patients.

Christopher J. Berry is a Michigan elder law attorney Dedicated to helping seniors, veterans and their families navigate the long-term care maze. To learn more visit http://www.michiganelderlawattorney.com/ or call 248.481.4000

The study looked at more than 6 million Medicare Advantage patients in 2009. More than 1 million of those patients received prescribed medications that are labeled “high risk,” while 5 percent received multiple high-risk prescription medications. Seniors are generally advised to avoid high-risk prescription medications and to ask for safer alternatives.

More than 100 medications are currently classified as “high-risk” for side effects when taken by seniors, while the same medications are not generally considered to have high-risk side effects for younger patients. Most notable, stated researchers, was the geographic variation found in the study: Southeastern-based patients were between 10 and 12 percent more likely to have been prescribed a high-risk medication than a patient living in the Northeast. Additionally, Caucasian seniors, female seniors and seniors who were low-income all were prescribed high-risk medications at a higher rate.

Researchers posit that many medical professionals are unaware of medications that are considered high-risk for geriatric patients.

Christopher J. Berry is a Michigan elder law attorney Dedicated to helping seniors, veterans and their families navigate the long-term care maze. To learn more visit http://www.theeldercarefirm.com/ or call 248.481.4000

Medicare Advantage is an alternative to regular Medicare created by Congress in an attempt to cut costs in 1997. … http://p.ost.im/dpdDVR

Medicare Advantage patients are generally subject to a small copayment whenever they see a doctor, after which the visit is completely covered. This is in contrast to having to pay a deductible and then coinsurance – typically 20 percent – which is usually the case under regular Medicare. This generally eliminates the need for a supplemental Medigap policy.

Another attractive feature of Medicare Advantage plans is that they usually cover products and services not covered by regular Medicare, such as prescription drugs and custodial care. Some also cover hearing and vision care, gym memberships, and other services.

These perks do not come without a cost. The primary method by which Medicare Advantage plan providers reduce expenses is limiting the doctors and other providers that a patient can see to a particular network. If a patient voluntarily sees out-of-network providers, they must pay the full cost. However, if a patient’s in-network physician orders medical services not offered by any in-network provider, the Medicare Advantage plan is required by law to pay for those services at an out-of-network provider as long as those services are normally covered by Medicare.

Another cost-cutting measure is to prohibit patients from seeing specialists on their own; patients must be referred to specialists by their primary care physicians. However, plan administrators strongly discourage physicians from referring patients to specialists unless it is absolutely necessary.

These are the primary differences between regular Medicare and Medicare Advantage. If you need to reduce your medical costs and do not mind having to see only in-network health care providers, Medicare Advantage may be right for you.

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A recent study by Brown University researchers found that more than one-fifth of older patients in the United States were prescribed high-risk medications.

To conduct the study, published in the Journal of General Internal Medicine, the researchers examined demographic data of 6.2 million patients who were enrolled in the Medicare Advantage health care plans during 2009. They found that 21.5 percent of elderly patients – more than 1.3 million – were prescribed high-risk medications. Five percent received multiple high-risk medications.

Amal Trivedi, one of the researchers, said that high-risk medications should be avoided for seniors, as safer alternatives are usually available.

There are approximately 100 medications that are classified as high-risk for seniors. Many of these drugs do not carry risky side effects for younger people. The drugs include common medications such as Benadryl.

The researchers said the geographic variation was notable: patients living in the Southeast were 10 to 12 percent more likely to receive a high-risk prescription than those in the Northeast.

Researchers said that doctors are often unaware of the differing side effects for elderly patients.

For more information about our elder law services, visit www.elderlawnewyork.com.

If you are a veteran and obtain your health care from the VA, you may think there is no need for Medicare.  However if you qualify for Medicare, by age or disability, then you should obtain your Medicare card and use it to supplement your VA care.

You should then look into Medicare Advantage.  14 million Americans are enrolled in a Medicare Advantage Plan, which covers hospital stays, doctor visits and other major medical needs.

Obtaining a Medicare Advantage Plan will not only help you maximize the value you are receiving in benefits, but, in many cases, it will also help you achieve better health and well-being.

If you want to know more about Medicare Advantage Plans, contact us at Legal Help for Veterans, PLLC.

Legal Help for Veterans, PLLC fights for veterans rights. We fight to make sure you get the benefits you deserve from the Department of Veterans Affairs. To learn more or contact an attorney about your Post Traumatic Stress, Traumatic Brain Injury, Mental Health, Sexual Assault, Hearing Loss and Tinnitus, Total Disability Based on Individual Unemployability, Medical Malpractice, or Aid and Attendance claim, visit http://www.legalhelpforveterans.com/ or call 800.693.4800