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    Category Archives: Medicare

    Medicare Won’t Pay Your Claim in Newport Beach? Appeal It!

    processed 906 billion outpatient insurance claims in 2010 – and refused to pay
    10 percent of them. But if you're a senior on Medicare with a denied claim,
    your odds of turning that around are surprisingly good if you appeal.

    Elderly Woman with NurseFew things are more frustrating
    than battling bureaucracy. But if you’ve had a Medicare claim denied – and
    about 10 percent of Medicare claims are denied – you’re well-advised to hang in
    there and fight the good fight!

    Reuters recently published an article explaining “How to appeal when Medicare won't pay.” It is
    not an uncomplicated process, but if Medicare refuses to pay for services your
    doctor recommends it’s certainly worth your while to fight. The numbers are
    fairly enlightening:

    In 2010, 40 percent of
    Part A appeals and 53 percent of Part B appeals were granted, according to the
    Centers for Medicare & Medicaid Services, which administers Medicare (CMS).
    Even in the case of big ticket durable medical equipment appeals, 44 percent of
    appeals were successful. More than half of appeals to Medicare Advantage and
    prescription drug plans are successful, too.

    Medicare consumer advocates offer these tips for filing an appeal:

    1. Send a letter. Your paper trail starts with the summary
      notice of coverage you get in the mail. Take this notice, circle the erroneous
      denial, and write out why you think it should be covered. Make a copy, and mail
    2. Don’t waste time. You have 120 days to file an appeal
      for Medicare Part B claims, and only 60 days for Medicare Advantage or Part D.
      If you filed for pre-approval and were denied, you have only 14 days to
      initiate your appeal.
    3. Be persistent. You have a right to four levels of
      appeal, so don’t quit until you have exhausted all of your options.
    4. Get help. For appeals beyond the first level, you may
      want to seek help from an elder law attorney.

    Contact your Newport Beach
    estate planning attorneys at Meier Law Firm to discuss all of your estate planning

    Reference: Reuters
    (November 13, 2012) “How to appeal when Medicare won't pay

    Choose Wisely with Medicare Part D Plans in Newport Beach

    Many Medicare beneficiaries are not aware that the open enrollment period for the Medicare Part D Drug plans is happening right now. You have until December 7th to determine if it is to your benefit to change plans, which could save you money.

    Have you signed up for Medicare Part D yet? Time is ticking, but don’t move before thinking through the options. Just because something worked this year doesn’t mean that it will be good for you next year, and big changes are afoot in many popular plans. So don’t get trapped in an inefficient plan.

    Here is a sobering statistic pulled by a posting over at the New Old Age blog on the New York Times: “only 5.2 percent of Medicare Part D beneficiaries manage to choose the most economical plan” (see “Part D, Part 2”). And why would that be? The market shifts greatly from year to year and providers frequently hide the gritty details with broad promises, but it’s those very details that
    determine your day-to-day life and much of your finances.

    For a short list of things to watch for and a broader view on comparing plans it may be helpful to review another article, “Avoid A Costly Medicare Part D Mistake Right Now through Forbes.

    The big things to watch?

    1. Increased monthly premium.
    2. Increased deductible amount.
    3. Changes in what drugs to plans cover and how well they cover them.
    4. Changes in the medications you take.
    5. Your plan may no longer be offered. In this case if you do nothing you will be enrolled in another plan that may not be the best suited for you.

    Remember: you must pick before December 7th! Choose wisely

    Contact your Newport Beach estate planning attorneys at Meier Law Firm to discuss all of your estate
    planning needs

    References: Forbes (November 8, 2012) “Avoid A Costly Medicare Part D Mistake Right Now

    Qualifying for Medicare Coverage May Be Easier for Newport Beach Families

    Elderly Woman with NurseTens of thousands of people with chronic
    conditions and disabilities may find it easier to qualify for Medicare coverage
    of potentially costly home health care, skilled nursing home stays, and
    outpatient therapy under policy changes planned by the Obama administration.

    Medicare may be opening the
    doors to many who previously had been turned away and left without coverage for
    home health care, nursing home stays and outpatient therapies on the basis of a
    less than positive “improvement” prognosis. This change of course may actually
    be the result of a nationwide class-action suit and an agreement from the

    For a perspective on the
    proposed settlement, turn to a recent article in The New York Times titled “Settlement Eases Rules for Some Medicare

    The Medicare board has had a
    longstanding practice to require a likelihood of medical or functional
    improvement before a beneficiary could receive coverage for skilled nursing or
    therapy services, whether institutional or home-based. That left many care
    recipients in a lurch. If this settlement goes through and becomes practice,
    then the requirement is no longer “improvement” but “maintenance.” Accordingly,
    Medicare will provide services if they are needed to “maintain the patient’s
    current condition or prevent or slow further deterioration.”

    Contact your Newport Beach estate planning attorneys at Meier Law Firm to discuss all of your estate planning needs.

    Reference: The New York Times
    (October 22, 2012) “Settlement Eases Rules for Some Medicare

    Time to Shop Around for Medicare Rx Plans

    Premiums for many popular Medicare
    prescription drug plans will soar next year – but seniors don't have to take
    the rate hikes lying down.

    Hunting season is open!
    Unfortunately, there’s little sport in this hunt: in Medicare enrollment
    season, maybe it’s time to hunt down and switch plans.

    You may need to draw on your
    survival skills for this hunt, too. All evidence points to some serious rate
    increases in Medicare prescription drug plans.

    As you likely are aware, October
    15 marks the first day of the enrollment period that extends until December 7.
    Nevertheless, if you haven’t read about the prescription drug increases
    elsewhere, a recent article in Reuters
    has reported that the potential increases may affect as many as 80% of all
    beneficiaries and even generate double digit rate increases for as many as 5.9
    million beneficiaries, or 29% of all beneficiaries. Check out the article
    titled “As Medicare drug premiums soar, it's time to
    shop around

    So, what’s the take away? “Shop
    around,” indeed! Be sure to look beyond the standard big 10 plans, because
    eight of the top 10 are showing such increases. For instance, under the Humana
    Wal-Mart Preferred Rx increases will be somewhere between 10%-23% for various

    Reference: Reuters
    (October 2, 2012) “As Medicare drug premiums soar, it's time to
    shop around

    Appeal Rights for Hospice Care Patients

    [The unfortunate case of Mr. Back and his
    case against Medicare] makes it clear that beneficiaries have the right to
    challenge a hospice provider’s refusal to provide a service that a doctor deems
    necessary, Mr. Deford said. But it’s disappointing because it doesn’t ensure
    that people receive a notice of their right to appeal when they enter hospice
    care, or that any mechanism exists for expedited appeals – an important
    protection for people who are dying.

    Medicare, and really any kind of
    health program from private insurance to public entitlement, is always disappointing
    when it fails patients due to bureaucratic dead ends. It’s even worse when the
    patient is a hospice patient.

    Much can be learned through the
    unfortunate case of Howard and Emily Back. Emily, now deceased, was a
    California hospice patient covered by Medicare. Howard appealed his wife’s lack
    of treatment through the court process. However, the court was quick to point
    out that there is an administrative appeals process through Medicare regarding
    its hospice care decisions.

    The entire case is detailed in a
    recent post in The New Old Age a blog
    through the New York Times, titled “Court: You Can Appeal Medicare Decisions
    About Hospice Services
    .” As
    this blog post notes, Emily was denied coverage for a pain medication while in
    hospice and in the last stages of life. Consequently, Howard paid for them out
    of pocket and later (after Emily’s passing) appealed to Medicare to cover the
    expenses for doctor-ordered medication. While initially told there was no such
    Medicare appeals process and was turned away, Howard learned otherwise.

    As Howard sought to set a
    precedent so future couples would not face the same roadblocks, the court has
    finally found and verified that a Medicare appeals process exists. In fact, one
    can appeal a Medicare decision regarding hospice services with a form labeled
    “CMS-1490S,” if the beneficiary believes they have been inappropriately denied

    This case is illustrative of the
    inherent problems that can occur when the competing interests of patient care
    and governmental bureaucracy collide.

    Reference: The New Old Age
    blog of The New York Times
    (September 7, 2012) “Court: You Can Appeal Medicare Decisions
    About Hospice Services

    Medicare Premiums Expected to Hold Steady in 2013

    Medicare beneficiaries will pay the same premium for prescription drugs
    next year as they did this year, the U.S. Department of Health and Human
    Services said.

    Finally, a little good financial
    news for seniors – your 2013 Medicare premiums are projected to remain the

    That’s right, the Department of
    Health and Human Services issued its estimate not long ago, and Businessweek reported it in an article
    titled “Medicare Drug Plan Premiums to Stay at $30
    in Coming Year
    .” Indeed, according to the estimate and bids from
    private insurers, the premiums for Medicare drug plans are expected to hold
    steady at the $30 average where they stand today.

    While this is welcome news in
    trying times, we can only hope that the estimate stands the test of 2013 and
    the current political posturings. For that matter, keep Medicare in mind as we
    glide to the annual enrollment period that begins October 15.

    Reference: Businessweek
    (August 6, 2012) “Medicare Drug Plan Premiums to Stay at $30
    in Coming Year

    Avoiding the (Medicare) “Doughnut Hole”

    Depressed Medicare beneficiaries in the so-called coverage doughnut hole were more likely to cut back on their antidepressants than those who had full insurance coverage, a study has found.

    Even with the Affordable Care Act (ACA) – Obamacare by any other name – in place and affirmed by the Supreme Court, the costs paid and lifestyles lived by many is being tied to the “doughnut hole.” This is especially true for seniors taking depression medications.

    As recently reported in Med Page Today, a new study by Yuting Zhang, PhD, of the University of Pittsburgh, Medicare may not fully cover depression medications for seniors, despite the ACA. The article is titled “Antidepressants 'Fall' Through Doughnut Hole.”

    If you are unfamiliar with the “doughnut hole” issue, you are not alone. It is the coverage gap created by Medicare Part D. For those whose income is at the lower end, there tends to be coverage. Likewise, for those who have an upper-end income, there is still coverage…with a gap in between.

    According to the new study, and sheer intuition, patients that fall within the doughnut hole are associated with a significant drop in medication use – 12% on average. That is always relevant, but perhaps especially so in the case of depression medication. While discontinuing any prescribed medication is never advisable, it is often easier to justify foregoing depression medication than other medications.

    I recommend reading the original article for more details regarding this study, should this issue be relevant to you or someone you love.

    Contact Meier Law Firm to discuss how we can help you protect everyone you love.

    Reference: Med Page Today (July 5, 2012) “Antidepressants 'Fall' Through Doughnut Hole

    Elder Depression – Preventative Assistance


    Depressed people are more likely to receive diagnoses and be treated in primary-care settings than elsewhere. Research shows that elderly people, in fact, prefer to deal with their primary-care provider on mental health issues. In that context, coverage of depression screening may help more Medicare beneficiaries get the help they need.

    As of last October, Medicare began coverage for a host of preventative services as part of the new healthcare law. One such service for the elderly is depression screening.

    This subject was recently addressed in a Kaiser Health News article, and it’s worth reading to learn more.

    The mind/body relationship is a complex one. It is hard to deny the overall health effects of depression, perhaps even more so among the elderly.  However, contrary to popular opinion, the elderly are not statistically more prone to depression than the general population.

    On the other hand, the elderly are more prone to types of system-wide health difficulties that may be exacerbated by depression. To make matters worse, people of the elder generations are generally less trusting of psychology and associate a social stigma with mental illness or any admission thereof. The combination of these two factors often, and unfortunately, complicates the lives of elderly persons and their families.

    Medicare now covers the cost of annual depression screening in primary-care settings with no cost sharing for beneficiaries. Medicare also covers 60 percent of the treatment for mental health problems, including depression. (Under a 2008 law, that figure is scheduled to rise to 80 percent in 2014.) If you or an elderly loved one may be suffering from depression, taking advantage of Medicare’s annual screening benefit may be a good idea and can greatly improve quality of life.

    Reference: The Kaiser Health News (April 3, 2012) “Medicare Now Covers Annual Screening For Depression

    Married Couples and Long-Term Care Logistics

    There’s another layer of rules for families in which the person hoping to get government help paying for long-term care has a spouse who is still living independently. States are treating such “well” spouses in dramatically different ways.

    Marriage is a unique economic and legal institution. Indeed, when it works out, marriage also means a happy lifetime of living with another. Of course, because life lasts longer and health wanes differently between persons, those unique economic and legal parts to marriage can translate into difficult times later in life.

    Against the backdrop of the in sickness portion of the vows, one difficulty that arises was addressed recently in a Wall Street Journal article titled Long-Term Care and Couples: Who Pays?. That difficulty is the phenomenon of the “well spouse,” the “ill spouse,” and Medicaid.  Practically speaking, if one spouse becomes chronically sick and needs long-term care, will the other spouse be driven into poverty?

    Marital assets, whether owned by the husband or the wife, are part of the equation when it comes to determining Medicaid eligibility. Medicaid is the joint federal/state government program to provide means-tested health care assistance to those who qualify.

    With both federal and state coffers bleeding red ink (with a few state exceptions), Medicaid money is tight, especially in terms of long-term care coverage — whether married or single. As the Wall Street Journal article notes, however, some states are treating the “well spouses” more generously than others regarding how much wealth they may retain while the “sick spouses” are receiving taxpayer support through Medicaid.

    I recommend reading the original article. Also, consider purchasing long-term care insurance so Medicaid does not become part of your future. In any event, a consultation with a qualified Elder Law Attorney would be prudent to evaluate your options.

    Reference: The Wall Street Journal (April 2, 2012) “Long-Term Care and Couples: Who Pays?

    Joint Tenancy Transfers Matter For Medicaid Eligibility

    A New York appeals court rules that a woman who, two years before applying for Medicaid, transferred money to a friend through joint tenancies in a claimed effort to avoid probate did not rebut the presumption that the transfers were made in order to qualify for Medicaid. 

    American law contains a principle that runs like a thread through very fabric of our jurisprudence – one is “innocent until proven guilty.” In other words, the law begins with the premise that one accused of wrongful conduct or motives, whether in a civil or a criminal context, is first given the benefit of the doubt until established otherwise by competent evidence to the contrary.

    Nonetheless, sometimes the tax courts, in their zeal to root out cheats, end up reversing that principle and end up turning on those vulnerable people who act only in the best of intentions: sometimes the elderly are “guilty until proven innocent” when it comes to the courts and Medicare disqualification.

    Consider the case of Mallery v. Shah (N.Y. Sup. Ct., App. Div., 3rd Dept., No. 513277, Mar. 1, 2012), as written about here in a recent post over at ElderLawAnswers.

    Here’s the deal: Paula Mallery wanted to be sure she had safely left her estate to her friend, Ron Stanton, and a moderate estate at that, without her family interceding and dragging the matter into the probate court following her death. Her reasons are her own (but you can appreciate anyone wanting to avoid a public bloodbath). It was something she thought about, even sought counsel for, and ultimately effected by adding Mr. Stanton as joint-tenant on her home and bank accounts. Mr. Stanton withdrew $141,410.12 between 2007 and 2008. Then, in 2009, when Ms. Mallery fell, required nursing home care, and ended up applying to Medicaid to pay for it.

    No, no, no. That was Medicaid’s response. Why? Medicaid maintained that Ms. Mallery had effectively made “uncompensated transfers” and was therefore subject to a 19 month penalty period (and more than a year and a half of such care is expensive!).

    To assume the absolute best of Ms. Mallory and her motivations – because it wouldn’t change the decision either way – she simply intended to pass her property quietly to Mr. Stanton, but ended up getting dragged into court. She appealed the decision and was ultimately rejected on the grounds that she never disproved the allegation her planning moves were motivated with an eye toward Medicaid qualification.

    It’s yet another harsh lesson in unintended consequences and the trials of qualifying for Medicare. In the end, planning for your assets after death must always also be about planning for those assets, and your medical care, throughout the remainder of your life. 

    Reference: (March 5, 2012) “Estate Planning Move to Avoid Probate Earns Medicaid Applicant Penalty Period

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