You Have Questions, We Have Answers

Steve Buttice, LBYD

Additionally, ensure that you:

• Review your benefits, they may have changed
• Check to make sure that your providers are still listed as in network
• Make sure your drugs are covered, watch for any new restrictions
• Look at your copays for the new year
• Contact your insurance company with any questions
• Consider consulting a local insurance agent, they know the environment for the new year as it applies locally, typically better than someone from a national
• organization
• Be an advocate for yourself, ask questions about what matters to you and take the time to get answers
• Remember that nothing comes ‘free,’ a low-cost plan is likely that way for a reason

Steve Buttice, LBYD

• Schedule an appointment with your insurance agent to update policies every year. At this point in life the needs of your care will change over time, and your insurance coverage will likely need amending to accommodate that. Always make sure you have the best coverage for your needs and medication, your plan should feel yours.
• If you or your spouse is a United States Veteran and either of you require daily assistance with medications or self-care, you may be eligible for a monthly Veteran’s pension to augment your Social Security or other pension income.
  Consider long-term care policies. If you already have it, read the fine print. These products have changed over the years so review your coverage to make sure you understand what it does and does not cover.
• Seek out a trusted third-party specialist to help navigate these things. There is a community of professionals that want to help you.

Steve Buttice, LBYD

Look for the signs.

• Are they using the rooms upstairs or having difficulty doing so?
• Is the yard as maintained as it used to be?
• Is there a risk of falling in the home?

Sometimes the answer is not for them to leave, but to augment the environment. Being vigilant about the signs of your parents being overburdened and assisting with altering their environment can keep them happy and healthy in their home longer.

Whatever happens, research assisted living homes now for the future. Figure out who offers what and where, and have an idea long before anyone needs a facility which you may prefer. Living By Your Design has a free senior community referral service that can help you match your needs and wishes with available communities in the area.

Steve Buttice, LBYD

It is important to note, however, that insurance agents can still be involved in this process, and many resources can be used other than Healthcare.gov. We advise you always speak to an ACA insurance professional to find what coverage you need and help to navigate this process beyond just pricing premiums.

Also - Open enrollment ends very soon, January 31st, 2016, meaning that unless your son, or any party interested, were to meet the specific criteria to apply out of the enrollment season - the window to apply for ACA insurance is closing fast.

As with any insurance, consider what level of coverage is needed for the individual. Many healthy 26 year-olds only seek catastrophic insurance with minor coverage for things like visits, and little worry for out of network services. This will vary radically on a case-by-case basis, so figure out what level of coverage works best for you. Of course, talking to a professional agent will likely be a huge help.

Steve Buttice, LBYD

First – If you are thinking of switching now, you are acting at the right time. You have until February 14, 2016 (it is always January 1st to February 14th each year) to opt in or out of MAPD, without special exceptions granted in certain circumstances year-round.

Second – This is truly a numbers game, if number crunching is not your cup of tea, please consult a professional, the following is for the DIY folks only!

To figure out if switching is right for you, find out approximately how much it will cost for your procedure, new medication, and each day you expect to spend in the hospital under MAPD and add all of that together (do not forget to take in to account your deductibles, out of pocket maximums, etc.). Now, divide that number by 12 and add it to your monthly premium, this number is your expected cost per month under MAPD. Now, if you find that your expected monthly costs are far higher under MAPD than Medicare with supplemental plans, then your answer is simple.

Finally – If you want to disenroll from an MA-only or a MAPD plan and return to Original Medicare during the allotted time mentioned above, you have a special election period (SEP) to join a Part D prescription plan.

• If you have a MAPD plan, you can either 1) submit a disenrollment request to your MAPD plan and then enroll in a Part D plan, or 2) the easiest way is to properly enroll in a Part D plan first, which then automatically disenrolls you from your MAPD.
• If you have an MA only plan, if just going back to Original Medicare - you must request disenrollment from your MA plan. If also enrolling in a Part D (RX plan), you may properly enroll in a Part D plan and that will cause your dis-enrollment in the MA plan.

Of course, you should always speak to a professional before committing to any large changes such as this, but it is always a good thing to have a general grasp on your insurance coverage for the year at the start of the year.

Steve Buttice, LBYD

In a medical setting, patient advocates can accompany clients to doctor appointments or outpatient rehab sessions.  As a result, they can communicate with medical staff and family members about the patient’s ongoing condition, medical compliance and related concerns.  They can also help with the filing of insurance and medical claims.  Through home visits, they develop a relationship with the patient and monitor health progress by taking vitals, overseeing the correct use of medical supplies and equipment as well as keeping track of medication usage.  They may also make suggestions for physical changes to the home environment to ensure safety by assessing fall risk and potential hazards due to limited mobility.

Ultimately the patient advocate can serve many functions, but their primary function is to advise and assist throughout the treatment process. Patient advocates are often vital for major decisions in the change of care or environment, such as when it is too risky to have a patient living alone, or when to begin worrying about quality of life over aggressive treatment. Ultimately, it is the job of the advocate to help patients and their families navigate the healthcare system.

Steve Buttice, LBYD

For instance, an insurance appointed advocate will likely have some level of the insurance company’s interests in mind. While it is unlikely they would ever provide bad or dangerous advice for the patient, they will likely have the reduction of cost to the insurance company in mind.

Advocates can also be appointed by the hospital itself, but they may also have their own goals in mind. Many hospitals receive a small penalty for patients being readmitted to the hospital within a certain period, and a hospital appointed advocate may have this or other things in mind when recommending a course of action.

While the difference may be slight, being the sole employer of a patient advocate does insure that their allegiances lie solely with the patient and their families. Perhaps just receiving a consultation from a private advocate to supplement your appointed advocate would suffice, but it is definitely something to keep in mind.

Steve Buttice, LBYD

For instance, if one seeks long term care in a facility based upon a struggle with dementia, usually two of 5 or 6 triggers are required for the insurance company to deem payment of the claim to cover the facilities costs necessary. These triggers are very specific, such as whether or not the person needs 24 hour care, and if not whether or not they can properly bathe or dress alone, and triggers such as eating without assistance.  Assistance could mean standby or substantial assistance.  Standby assistance is much easier to meet.

The reason this question comes up so often is that these triggers, and the failure to prove them to insurance companies, can often lead to a lack of payment for coverage that has been purchased and is, in fact, owed. The difference between understanding the triggers in insurance plans purchased, or to be purchased, can be the difference between many thousands of dollars in payable claims each month.

My advice: seek professional help both when purchasing your LTC plans and when it comes time to make a claim.

Steve Buttice, LBYD

• Prepare legal documents in advance (any possible future inheritance to be changed
• Align insurance with future needs (review beneficiary arrangements)
• Get in touch with the whole family, get them on board with any plans now if possible
• Investigate, and potentially contact, home health and facility options
• Monitor the disease, be prepared for changes before they are necessary
• Stay informed! Be realistic.  Ask questions and seek out professional guidance

It is important to remember you are not alone. Utilizing tools now can take you a long way in the future.

Steve Buttice, LBYD

If considering home health care the questions you should ask are things like:

• A tough question - When should my parents stop driving
• Who will take care of them
• Who will pay for it
• Is home health a long-term or short-term solution

Similar questions can be posed for facilities, and you can find a good deal of information on local facilities at http://www.livingbyyourdesigninc.com/facilities

The key to any plan for later years is tailoring to fit your family’s specific needs.  Remember, your parents are the captain of their ship.

Steve Buttice, LBYD

Jargon and industry terms are sometimes difficult to understand, for many families going through this time in their lives. When we say the term ‘legal documents,’ typically we are referring to Powers of Attorney and a will, or any preparatory legally binding document that gives direction for the future.

Primarily, this includes the following, all of which should be discussed in detail with all parties involved and should only be done through a lawyer:

• Getting a will written that includes advance directives and wishes.
•  Include POA (powers of attorney) for healthcare and finances.
•  In some cases a trust may be in order.

There is a lot to say on this matter, and each family will have different needs. My recommendation is to secure legal advice if there have been changes since you last had legal documents drawn up, and assess where your family’s greatest needs are.