Switching from a Medicare Advantage plan to regular Medicare plan - has anyone had any experience with this for their parent? Pros and cons?
My 94yo mother, who is still of sound mind (short of forgetfulness) insists on aging in place and is house bound. I'm her long-distance caregiver (two hours away and FT job). I travel every other weekend to care for her and her large home. She developed edema and last year was hospitalized twice for cellulitis in her legs. She has had a home health nurse to wrap her legs since, as with her back issues she has trouble keeping her legs elevated; thus, it is difficult to keep the swelling from occurring. The leg wraps are the only solution for her as she can't get compression stockings on, nor can others get them on her because she has little strength in her legs. Recently, continuation of her insurance coverage for this was denied as the nurse's assessment indicated her legs were healed. However, her legs began weeping within 12 hours of the removal of the wraps. After many phone calls to the nursing agency, a re-assessment was completed and the insurance company authorized 8 more weeks of visits through the first week in December. The nursing agency suggested we switch from my mother's current Medicare Advantage plan to regular Medicare, as a regular Medicare plan usually does not require prior authorizations. Has anyone had this experience and how did it work out? Did switching to regular Medicare prove to be a better choice? Thanks for any insight.
SHIP is Senior Health Insurance Program.
They are people that have been trained to help you navigate the various Health Plans and they can help find the one that is best suited for the least cost.
They are not paid by any Insurance Plan so they are not beholden to any of them and they will give you unbiased information.
It cost twice what my Kaiser Advantage did. At the time of his death 5 years ago it was 250.00 a month, so I can only imagine cost today. So one comparison is that the non-advantage program is almost always more costly.
I don't know that home care would have provided him more than had he been on an advantage, with it's limitations. BUT, I do know that most insurance will not continue to cover in home services for this forever.
I really cannot "guess" what would be covered by a "not-advantage care" policy in terms of a need for ongoing in home visits daily; most insurance will not cover this.
With no one there to assist your mom when she can no longer care for herself or even manage, because of other factors, to keep her legs elevated, this will go on and will be a constant which requires, in all truth, daily management.
You may be looking at a situation that requires daily care. Will your mother be able to manage that? Or does she need someone with her to keep her legs elevated, wrapped, monitored daily?
I can't find an answer now, for mom's daily needs, in an "insurance supplement". I do not believe that any will pay for daily management by medical. And without her legs staying elevated I am afraid this is chronic and ongoing for her. The time when she can manage alone at home is almost over, I am afraid is my best guess.
I wish you good luck. You might consider checking on any policy how long they would care in home for such a condition, because this is chronic and ongoing.
I am by the way assuming that this is "dependent edema" by diagnosis and not Congestive Heart Failure which in the case of right sided failure would cause edema, require diuretics and their emergency trips to the bathroom and monitoring for potassium depletion and etc. I know you are hoping your mom can remain at home and die as home (the hope of all us oldsters). But you are skating close to the edge of what's safe, I am fearing.
Get on Medicare, find a good supplemental plan, and stop having your treatments being denied.
By the way my father had leg swelling and he had an electronic compression device that helped a lot. His vein doctor prescribed it. We used the device a half hour each day and it really kept the swelling at bay.
I really can’t answer your insurance question.
See also this question today, and it's answers. This medicare coverage mentioned available apparently only to patients without advantage plans:
Does medicare cover in-home care for patient with cancer? - AgingCare.com.
This could pertain to mom's care for sure, I would think.
I couldn't copy paste the link, but that is the title of the question and it is in todays threads. You will find it by going up to timeline in blue, finding magnifying glass, typing question into the search bar. Good luck.
I tried one time to check on how to get my friends changed. A broker told me the problem was when you go on Medicare it is extremely important that you make the choice for the right one the first time you sign up.
Part A no problem. Part B should be no problem. The problem is the MediGap plan doesn’t have to take you after the initial opportunity to sign up when you first registered. You must put down all the preexisting conditions and they will charge more than if you had just signed up when the preexisting didn’t count against you. Also each year as you get older, it will go up. There are about a dozen plans to choose from in my area for the medigap. You put in your zip code on the Medicare site and all will appear. You can see the prices there for the first time applicants.
I have a good friend whose sister has an advantage plan. She has just been diagnosed with bladder cancer. First of all she had two cultures (supposedly) for an UTI and had been on antibiotics. My friend just happened to call and found that her sister sounded so bad that she called 911 from several states away. She needed 6 pints of blood. Then the hospital experience was a nightmare then she went to a rehab, 1 of 3 that the advantage plan would cover. On the Medicare site there was a red hand meaning no don’t go there, abuse, on two of the three.
There she was thought to be not doing so well in therapy when what the problem was (discovered by my friend when she arrived) she had low oxygen. Back to the hospital to have blood clots treated in her lungs. The orig surgeon had taken her off blood thinners because she was bleeding. Next she learned she couldn’t go for the best cancer treatment because they wouldn’t take her plan. So my friend wants to change her sisters plan but I don’t know what she has found out. She wants to get her to better care than she can find in her sisters small rural town with the advantage plan.
Here is a link to an article recently posted on JIMMO. I posted one there as well regarding appealing advantage plans when they deny coverage. This might help inform you on helping your mom get services.
Let us know what you find out. We learn from one another.
https://www.agingcare.com/discussions/jimmo-settlement-490035.htm?orderby=recent
As others have suggested, time to work through some plans for the future now as it will get worse/harder. And, I would advise getting with a licensed elder care attorney in the State where your mom resides as each State law/regs are different.
There are many "moving parts" to figuring out what is best. But so-called regular Medicare is better overall as it does not have so many impediments to coverage. That said, it will be more expensive. Medicare Part A (inpatient hospital care, and post acute care such as a limited home care or SNF option) does NOT have a premium, but there is a deductible.
Your mom will need Medicare Part B, which covers things like doctor visits and some "B, physician administered drugs such as an infusion." Medicare Part B has a monthly premium. I believe the standard Part B premium is about $175 for 2025. That said, if you mom's adjusted gross income is above a certain amount, the premium might be more. There may also be a "late" Part B premium if one did NOT sign up for Part B when first eligible. This is the Part B Late Enrollment Penalty." Part B has a deductible and a 20% cost sharing, more money.
Your mom will need Medicare Part D for outpatient drug coverage as original Medicare does NOT cover drugs other than those administered in the hospital, in a post acute care facility or in a doctor's office, vaccines too. The premiums for Part D depend on the plan one chooses. First, make sure the outpatient drugs she takes ARE covered by the D plan you are considering. Just do not choose based on the premium.
Medigap (another premium) may cover some of the out of pocket costs and cap out of pocket costs. There are different plans to look at and compare.
You said your mom is "homebound." If she meets the Medicare definition of "home bound" she may be entitled to other regular/traditional Medicare benefits.
If she has other issues -- has end stage renal disease/kidney failure, for example -- she may be entitled to other benefits.
If she meets the definition of "disabled" for Social Security, again she may be entitled to other benefits.
Some states have so-called PACE programs that cover more things and she may be entitled to that.
Lastly, there are various Medicaid-related (for low income folks) possible options if she "spends down."
This is very complex and difficult without proper legal advice. Yes, that too will cost money, but it may give you and her a better understanding to make the right decisions so she gets the best care possible.
Good luck with this
https://a.co/d/dn9lhx5
There are also other magnesium supplements that she could take orally as well.
Medicare: My mother has been on original Medicare since she was 65 and is now 97. She also has a supplemental plan G. Since I have been handling her medical issues, including hospitalizations, surgeries, doctor visits, and now hospice care, she has not paid one penny in medical bills. Not one penny.
Last May I turned 65 and am now also on Medicare. Before deciding on an advantage vs traditional medicare, I did my due diligence and it became clear to me that original Medicare with a supplemental plan is the way to go.
Even though people think that an advantage plan is "free", it's not. You still pay the $174.00 every month - it just goes to an insurance company. And now you've brought another entity who can reject your claims into your medical issues. No thanks. Doctors and hospitals don't have to take Advantage plans from what I understand, but they do have to take Medicare unless they want to pay a penalty.
So I went the same route as my mother with original Medicare and a supplemental plan G through Mutual of Omaha. I am assuming that I will have the same level of payments as my mother if and when I begin to need medical treatment.
Advantage Plans are only useful when you 100% healthy. It gives you lower co-pays and sends you free bandaids and acetamenophin, and gives you health club access (and so does my gap plan). But IMHO when the rubber meets the road you don't want to only have an Advantage plan if you become seriously ill or injured. You'll pay more in office visit co-pays, but it'll cover a lot more of your medical expenses. I don't need any pre-approval for anything with my gap plan.
Keep another thing in mind. In either plan, CMS will still dictate the number of treatment coverage since the diagnosis code will not change.
AlvaDeer's point is also good. If her mother had Medicare + Supplement right along, she wouldn't usually have needed preauthorizations, but that doesn't mean treatment would have been continued indefinitely if there was no improvement. Some limits are imposed by Medicare itself; for example, limits on PT and OT treatments for a condition.
Of course we know about our on experiences and not all experiences but if a person needs therapy to maintain a level of ability they can indeed continue with PT and OT as my mom had OT until her death due to not being able to use her right arm w/o it.
(SHIP = Senior Health Insurance Plan)
These are trained counselors and they do not work for any insurance plan so are not beholden to any of them They will look at all the medications, the current plan and compare and find a plan that will work best.
The service is free.
Just do a search for "SHIP counselor in my area" Many Senior Service Centers have one or more but you will have to make an appointment....pretty busy this time of year.
Second I want to emphasize again--and you should be able to check on this--that I don't believe. Medicare, regardless of the kind of plan, will pay indefinitely for someone to come into the home to wrap a person's legs. There are other pros and cons of the different kinds of plans, but the deal-breaker should not be whether or not pre-authorization is required for someone to come in to do the wraps. The result in this situation will probably be pretty much the same.