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Medicare Updates for 2023 AEP Part 1




I thought it was difficult understanding the stages of Dementia when I initially became Mom's caregiver. Understanding her needs quickly revealed a dotted line to the services and providers I needed to be familiar with. Often times, her hesitation of going to the doctor was about what she could afford. We had many conversations with her side mainly ending up with "I don't need it."

As the seasons passed and her decline was more apparent, I realized that statement of not needing care was more about the fear of the unknown and not understanding how her needs would be met, especially when it came time to having to leave her home to receive care. When I started to explain what the doctor shared with us and connected it to insurance coverage she started to trust the process and accept the care was a good thing. Next I explained that many of her care needs could be met in her home so she no longer felt the fear of her physical limitations too.

For those new to this type of insurance, let's first go over what Medicare is with the difference between Medicare and Medicaid.

>What is Medicare?

This government program began in 1966 under the Social Security Administration and is now administered by the Centers for Medicare and Medicaid Services (CMS.gov). It is a comprehensive program of health insurance designed to assist the nation's elderly and those with qualifying special needs in meeting hospital (emergencies and surgeries), medical (doctors and treatments), and other health costs (services and medicines). Medicare is available to most individuals 65 years of age, older, and younger people with disabilities.

>What is the difference between Medicare and Medicaid?

Part A is considered "hospital insurance." Part A also covers skilled nursing facilities and home health care. Most Americans who worked in the U.S. already paid for it through their payroll taxes over 40 quarters or ten years, so you do not have to pay for Part A premium. If you never worked, you may still qualify for premium-free Medicare Part A if married, through your spouse's work history, or based on specific medical conditions.

Part B, also called "medical insurance," is paid through monthly premiums. Part B covers the medically necessary services to treat illnesses, including doctor office visits, lab work, x-rays, and outpatient surgeries. It also covers preventative services such as cancer screenings or flu shots.

>What is the difference between Annual Enrollment Period (AEP) versus Open Enrollment (OE)?

General Open Enrollment (OE) is for people turning 65 who get insurance on the individual market during January to March. This is the initial application for Part A & B. Annual enrollment is for employees or those already signed up who get health insurance as part of their benefits during October 15th to December 7th.

>Does Medicare cover Home Health Services?

Some services are covered while others are not. Caregivers need all the help they can get so understanding the paid and unpaid services will be helpful. According to CMS.gov, Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) cover eligible home health services as long as it is part-time or intermittent skilled services and the recipient of care is "homebound." By home, this refers to your loved one not being able to leave without the use of a cane, wheelchair, walker, or crutches. They need special transportation or help from others to leave their home because of illness or injury. Especially, if leaving the home is not recommended because of their condition and would cause a major effort.

Covered home health services include:

  • Medically necessary part-time or intermittent skilled nursing care (other than drawing blood)

  • Physical therapy

  • Occupational therapy

  • Speech-language pathology services

  • Medical social services

  • Injectable osteoporosis drugs for women

  • Durable medical equipment

  • Medical supplies for use at home

Your loved one's doctor or attending practitioner will create the order for you to hire the home health agency. However, the agency of choice must be Medicare certified. Keep in mind that your doctor may recommend you receive services more often than Medicare covers or services that are not covered by Medicare. Be sure to ask the doctor questions about the intent for the care with expected results so you have an idea of costs involved in case part of it becomes out-of-pocket fees.

Home health service NOT covered:

  • 24-hour-a-day care at your home

  • Meals delivered to your home

  • Homemaker services (like cleaning, laundry, or grocery shopping) that are not related to the doctor's prescription for care.

The assistance with daily activities of living or ADLs (like bathing, dressing, or toileting, transference, meal prepping, or medication management)

As a patient of Medicare, the federal law protects your rights by:

  • Allowing you to choose your home health agency. However, those under a managed care plan will need to choose from agencies in their plan.

  • Expect to have your property treated with respect.

  • Be provided with a copy of your care plan and participate in the decision about your care.

  • Allow you family or designated guardian act on your behalf.



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