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By John M. Bigler Medicare beneficiaries now get to choose a prescription plan for the first time under the new Part D of the Medicare program. The new prescription drug program will take effect Jan. 1. Most readers have already been inundated with information regarding Part D prescription coverage.
In my opinion, Medicare Part D is not the magic elixir that the current administration says it is and, in fact, falls quite short. However, information has to be assimilated and choices must be made. For most Medicare beneficiaries, one of the most helpful sources of information is "Medicare and You", the publication issued by the United States Department of Health and Human Services. That publication is distributed every year, but this year it actually has a very good explanation of Medicare Part D, as well as information regarding local plans and rates to help beneficiaries make intelligent choices.
Medicare Part B is medical insurance that helps cover physicians' services, some outpatient services and therapy, durable medical equipment, prosthetic devices, ambulance services, home health services not covered under Part A, preventive screenings, some nutrition therapy, flu and pneumonia vaccines and some therapeutic shoes. Part B involves a monthly premium; if one chooses to have Part B in 2006, the cost will be $88.50 per month, which will be taken directly out of the beneficiary's check.
The problem with Medicare, unlike Medicaid, is not obtaining eligibility but accessing the benefits. Typically, the key is whether or not an individual is receiving acute or skilled care as compared to custodial care. I lecture constantly about this issue and what disturbs me is the unwitting use of the term custodial by both people in medical fields and attorneys. Once the level of care is labeled as custodial, then Medicare will not be available. In fact, the Medicare regulations have a very liberal definition of skilled care. Skilled care is described as the total aggregate level of care received including observation, monitoring and assessment of a patient's condition. Unfortunately, the proper standard is not always applied and many people are denied improperly. What Medicare beneficiaries always have to understand is that it pays to appeal a denial. It may necessitate several appeals and it typically requires patience as it can take many months, and sometimes even years, before a favorable decision is rendered. However, with persistence, many denials of coverage under Medicare are reversed. Beneficiaries should be aware not to accept a notice of non-coverage as final.
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Since there is so much information about Medicare Part D at this point, I thought it would be a good time to look at the traditional Medicare coverage in Parts A and B, which have been in effect since 1965. The beauty of the Medicare program has always been that it is not based on financial need but is rather an entitlement. To qualify, one simply needs to be 65 with a significant work record (30 quarters) or receiving Social Security Disability benefits for two years. Once qualified, the beneficiary automatically receives Medicare Part A, which helps to cover inpatient care in hospitals, the first 100 days in skilled nursing facilities, hospice care and some home health care. If you do not qualify automatically for Part A, you may be able to buy into the program - but at $393 per month, it's not cheap. In 2006, Medicare Part A will cover the first 60 days of a hospital stay with a one-time $952 payment. For days, 61 through 90 of a hospital stay, there's a co-payment of $238 per day. Each beneficiary is also entitled to 60 "lifetime days". This is a one-time benefit; once these days are used they cannot be replaced. For the 60 lifetime days there is $476 per day co-payment. Medicare benefits end after 150 consecutive days in a hospital. If an individual has at least a three-day qualifying hospital stay and then goes to a skilled nursing home facility, the first 20 days there can be covered in full by Medicare and the next 80 days are covered with a daily co-payment of $119.00. There is no cost for Medicare approved home health services or hospice care as long as one qualifies.