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Medicare Nation

How much would you pay out-of-pocket for a five day hospital stay on Medicare? The majority of people have no idea! The problem with Medicare is there is too much information. An overwhelming amount of information and not enough resources. Medicare Nation solves that problem by educating you on all things Medicare, because there are not enough resources out there! This podcast will educate you about the components of Medicare, the different categories of Medicare Plans and Medicare benefits. On other episodes I’ll interview expert guests in the health and wellness field, about diseases, Medicare issues and current changes to the Medicare program. Medicare Nation is dedicated to answering all your questions about Medicare. Expert information and insights regarding Medicare and you! Further information can be found on www.callsamm.com Give us feedback on Facebook! www.facebook.com/MedicareNation
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Now displaying: April, 2016
Apr 29, 2016

Welcome Medicare Nation! 

Today, I want to tell you about the federal government program called The Extra Help program, also called Limited Income Subsidy (LIS).  If you never heard of this program, you may be missing out on some additional subsidies for your prescription drug purchases. So let’s walk through the program to see if you qualify.

Qualifications for the Program:

1. Must be a resident of one of the 50 states in America

2. Your resources (savings, stocks, bonds, 401k etc.) cannot exceed $13,640 (married $27,250)

3. Your annual income cannot be more than $17,820/yr (married $24,030)

4. If you support someone else who resides with you (not your spouse), you may qualify for a higher threshold

 

How to Apply for Extra Help:

The easiest route is to apply through Social Security

1. Apply online: www.ssa.gov - click benefits and then apply for extra help 

2. Call Social Security directly at 800-772-1213

3. Go to your local Social Security office - find locations at www.ssa.gov 

  • Make sure you keep a paper trail of your application. 
  • If you go in person, get them to stamp your application to prove they received it

 

 

Automatic qualifications:

  1. On Medicare and Medicaid you are a dual enrollee
  2. If you receive SSI income
  3. If you receive Medicaid

 

You have to re-qualify every year. Social Security will send you a letter and determine your eligibility for the next year around August.

You can get an overview of the Extra Help program by emailing support@themedicarenation.com and ask for the Extra Help pamphlet.

 

You can call me with questions at 855-855-7266.

Do you have questions or feedback? I’d love to hear it!

I may answer one of your questions on the air!

email me:

support@themedicarenation.com

Thank you for listening! If you enjoyed this podcast, please subscribe and leave a 5 star rating and review in iTunes! (Click here)    

Find out more information about Medicare on Diane Daniel’s website!

www.CallSamm.com

 

Apr 22, 2016

Welcome Medicare Nation!

Hot Topic – The Comprehensive Care For Joint Replacement Model (CJR Model)

  1. Hip Replacements & Knee Replacements are the MOST COMMON Inpatient Surgery for Medicare Beneficiaries.
  2. In 2014 over 400K procedures were done, which cost Medicare over 7 Billion $ for the Hospitalization for these procedures ALONE.
  3. Hip & Knee Replacement Surgeries can require long recovery time & long Rehab periods.

I KNOW!  I’m not even on Medicare yet, and I’ve had TWO Arthroscopic Knee Surgeries, and each surgery took me about a good 6 MONTHS to recover.

 

This is the SCARY PART!  

The Quality & Care you receive VARIES from one Hospital to the next!

Complications like –

  1. Infections received at the hospital …….OR
  2. Implant Failures

Can be 3X Higher Performed at Some Hospitals More Than Other Hospitals.

To me……that is just NEGLIGENCE! 

When you go into a hospital……you expect to receive the best care, a clean environment and YOU SHOULD NOT  CONTRACT  ANY INFECTION OR DISEASE from the Hospital you’re being treated at!  That’s what you Expect from a Hospital…..NOTHING LESS. But……it is apparently going on RIGHT NOW Nation!

And it takes a CMS LAW or MODEL PROGAM to prevent it from happening in EVERY Hospital? Aye,,yi,,,yi.

 

WHY IS THIS HAPPENING TO YOU?

In episode 34 on Medicare Nation, you listened to Melissa’s Story.

Melissa’s story is about the struggles she had with her mother, who suffered a broken hip and the FRAGMENTED care her mom received while in the hospital and the struggles she had in moving her mom to a skilled care facility and then setting up home care physical therapy for her mom.

That is why all this is happening Nation!

There is a LACK OF COMMUNICATION, between Hospital Staff, other Doctor’s, Skilled Nursing Facilities and Home Care Physical Therapy.

NO ONE is talking to anyone else! The LINKS in the CHAIN of Patient Care is BROKEN, and YOU are paying for it! 

This FRAGMENTATION of Care is causing LONGER RECOVERY TIMES, HIGHER HOSPITAL RE-ADMISSIONS & HIGHER OUT OF POCKET COSTS FOR YOU & FOR MEDICARE.

The Comp Care Joint Replace Model Addresses the LOW QUaLITY CARE & Higher Costs that come from this FRAGMENTED CARE, by –

PROMOTING CO-ORDINATED PATIENT CENTERED CARE!

Imagine that Nation!  Putting the Patient 1st! What a New Concept!

 

HOW  WILL  THE  CJR  MODEL  WORK?

Started  April 1,  2016

  1. The hospital in which the hip or knee replacement and/or other major 

leg procedure takes place, will be accountable for the costs and quality of related care  from the time of the surgery through 90 days after hospital discharge—what is called an   “episode” of care.

  1. Depending on the hospital’s quality and cost performance during the 

episode, the hospital will either 

  1. Earn a financial reward     OR, 
  2. beginning with the second performance year, be required to repay Medicare for a portion of the spending. 
  3. This payment structure gives hospitals an incentive to work with 
  1. physicians, 
  2. home health agencies, 
  3. skilled nursing facilities, 
  4. and other providers to make sure beneficiaries receive the coordinated care they need 

The goal is reducing avoidable hospitalizations and complications. 

Hospitals in the model will be provided access to additional tools – such as spending and utilization data and sharing of best practices -- to improve the effectiveness of care coordination. The model also gives providers additional flexibilities that are not otherwise available under Medicare so they can better manage the care of patients, including patients who are at home.

By “bundling” payments for an episode of care, hospitals, physicians, and other providers have an incentive to work together to deliver more effective and efficient care.

The CJR model is being tested in 67 geographic areas throughout the country, and nearly ALL hospitals in those geographic areas are required to participate.

The CJR model supports Health & Human  Service’s  efforts to transform the health care system towards one focused on better quality care, smarter spending, and healthier people through care transformation and payment reform.

WHAT  AREAS  ARE  PARTICIPATING  IN  THE  CCJR  MODEL

Over 800 Hospitals across the US are participating, in 67 Geographical Locations.

Areas were determined based on statistical population data, with populations of over 50K residents.

Here are a Few selected Areas:

  1. Florida – Broward, Collier County, Gainsville, Hernando, Hillsborough, Indian River County, Lake County, Martin, Miami-Dade, Orange County, Osceola, Palm County, Pensicola area, Pinellas, Pasco, Santa Rosa County, Seminole County and St. Lucia County

 

  1. California – Alemeda County, Contra Costa County, Los Angeles County, Marin County, Orange County, San Francisco County, San Mateo, Stanislaus County, 

 

The rest are on the CMS.gov site. Search “CJR Model Geographical Areas,” To find out if a Hospital or County where you reside is participating.

OR

You can go to my website, www.callsamm.com  and I’ll put up a PDF of the Counties participating in the CJR Model program for you to request.

 

 

You can also download a copy of the Federal Register, which is a daily journal of the US Government.  The FINAL Rule for the CCJR Model is there in LONG Form

https://goo.gl/hN44cm

Federal Register/ Vol. 80, No. 226 / Tuesday, November 24, 2015 / Rules and Regulations 

www.callsamm.com - has all of this information available for you.

 

Do you have questions or feedback? I’d love to hear it!

I may answer one of your questions on the air!

email me:

support@themedicarenation.com

Thank you for listening! If you enjoyed this podcast, please subscribe and leave a 5 star rating and review in iTunes! (Click here)    

Find out more information about Medicare on Diane Daniel’s website!

www.CallSamm.com

 

 

 

 

 

 

Apr 15, 2016

Welcome Medicare Nation! It’s tax season! Today is April 15th and it’s the dreaded tax deadline day! It’s this time of year that people realize they need to make some changes to their Medicare plan. However, many people don’t realize that you can’t just make changes anytime you want to a Medicare Advantage Plan. There are specific times that you can make changes, and then you have to live with them until the opportunity arises to make changes again.

 

Here’s quick guide to making changes to your Medicare Advantage Plan:

 

  1. You make your initial selection of your Medicare Advantage Plan when you enroll at 65.
  2. During annual enrollment from October 15 to Dec 7th.
  3. You can dis-enroll from January 1- Feb 14th, but you would have to go on to original Medicare because you cannot switch to another Medicare Advantage Plan at this time.
  4. You may have a “Special Election” that allows you to change your plan.

 

That Special Election for Medicare Advantage is what we want to focus on today.  There are certain circumstances that can qualify you to have this option.

 

 

Moving Your Residence:

 

  1. If you move your home and your new location is not in your plan service area. You would need to notify Medicare as soon as possible, because you only have the rest of the current month and the following 2 full months from your move as the Special Election Period.
  2. If you move to a new address and your plan still is in your service area, but by moving you now have new options available to you that you didn’t previously have, then you would have a Special Election Period to change to one of those previously unavailable plans.
  3. Snowbirds that live in 2 areas have to determine which of those places is your primary residence. Where you vote and where you pay taxes are going to determine your primary residence.
  4. If you are out of the country for a period of time and now you are coming back to the US, then that could trigger a Special Election Period.
  5. If you are moving into a longer term care facility or rehab facility with round the clock skilled nursing care, you would have a Special Election Period when you move into the facility, while you are at the facility and when you move out of the facility. 

 

 

 

Losing Coverage:

 

  1. If you leave a job, or the union through retirement, etc.
  2. If you had an involuntary loss of drug coverage that was as good or better than Medicare drug coverage, that triggers an SEP. Or if you have had drug coverage through Medicare Cost Plan and left that job.
  3. If you lost coverage through the PACE Plan.
  4. If you had Medicaid and lost eligibility because of the income requirements.

 

 

 

You have a chance to get other coverage:

  1. If you had coverage from an employer and it was better than Medicare, you could go on it.
  2. If your employer had better plan coverage and you wanted to get on that plan.
  3. If you wanted to get into a PACE Plan

 

When there are plan changes with Medicare Contracts:

 

  1. If a provider was sanctioned by CMS, then you would be able to choose another plan.
  2. If Medicare terminated a contract

 

 

Dual Member (Medicare and Medicaid)

 

  1. You may get extra help with drug coverage
  2. May have been on a Medigap plan, changed to a Medicare Advantage Plan and then wanted to change back, you can change to a Medicare Supplement plan during your first year of coverage.
  3. SNIP Plan - for chronic conditions - may leave Medicare Advantage to go on the SNIP, or yu no longer qualify for a SNIP, so you can choose another plan.

 

 

 

If an error was made by a federal employee when you signed up for Medicare, and you can prove it, you may be granted an SEP.

 

 

*****You cannot get an SEP because your Doctor left the network********

 

 

 

If you have a Medicare Supplement - a Medigap plan, you can change plans whenever you want because there is no SEP.

 

Precautions:

 

If you have a chronic illness, cancer, cardiovascular disease, a plan does not have to take you after your first year of enrollment. You need to be careful and make sure you are going to be able to get coverage when you change plans. The other company might not take you due to pre-existing conditions and your old plan may not take you back. They can discriminate due to pre-existing conditions.

 

The price of these plans do change as you age, so keep that in mind.

 

Original Medicare:

 

Part A, B and D - you are on all the time, so you don’t make changes unless it is open enrollment or an SEP. 

 

 

www.callsamm.com - has all of this information available for you.

 

Do you have questions or feedback? I’d love to hear it!

I may answer one of your questions on the air!

email me:

support@themedicarenation.com

Thank you for listening! If you enjoyed this podcast, please subscribe and leave a 5 star rating and review in iTunes! (Click here)    

Find out more information about Medicare on Diane Daniel’s website!

www.CallSamm.com

 

Apr 8, 2016

Welcome Medicare Nation! Today we wrap up our “trilogy” about Care Coordination by talking to Patient Advocate Karyn Rizzo!

 

Karyn wrote the book - Aging in America - What you need to know about Navigating our Healthcare System

 

Karyn’s book is available on Amazon. It covers everything from finding a primary care physician, choosing Medicare programs, and also some information for LGBT friendly providers, and safety tips, fall prevention etc. It just covers lots of real life issues that you face, including respite and how to take a break from care giving!

 

The book came out of the needs Karyn saw in her work everyday! She knew there was so much information she needed to cover, so she created a powerful resource in the book!

 

Fall prevention tips that Karyn provides in the book:

 

  1. Eliminate rugs in the bathroom and other rooms of the house
  2. Check the types of shoes to make sure they don’t contribute to a fall
  3. Falls happen in the middle of the night going to bathroom, so install rails
  4. Is walker or cane easily accessible from the bed?
  5. Do you have motion sensor lighting?
  6. Medications can contribute to falls

 

Another great resource on fall prevention is mayoclinic,org

 

Advocacy for Patients is important today because of the following factors:

 

  1. Healthcare providers don’t have the time to spend with you explaining things
  2. Insurance companies have complex coverage rules
  3. Healthcare treatment options are more complicated than ever

 

 

 

 

What a Patient Advocate Does:

 

  1. Individuals that directly advocate for the patient
  2. Neutral parties hired by the family - not employed by hospital or insurance company
  3. Evaluate the care plan for the patient
  4. Advocate will put together a care plan that meets the patient's needs
  5. Works through the process of appealing insurance and hospital decisions
  6. They know the system, the lingo, and the rules, so they can use them to the patient’s advantage
  7. Knows what programs the patient is eligible for and how to get you on the right program for them
  8. Advocate can also help involve other specialty Physicians to evaluate the best treatment plan for the patient
  9. Advocates can also help navigate care options for Hospice and understand when it is appropriate and when other options are better for the patient.
  10. Hospice does have a Home Health division and it can be confusing between that and end of life Hospice care, so the patient advocate can make sure you are on the appropriate service.
  11. Healthcare regulations vary from state to state, so it’s important to get accurate help navigating the system.

 

 

 

Where do you find a Patient Advocate?

 

Sometimes called a Geriatric Care Manager, Social Service Agencies - There is a national website that provides a directory of caregivers:

 

 

CareManager.org

CareGiver.org

AgingGuidebook1.com - Karyn’s website has TONS of resources

 

 

What type of Licensing does a Patient Care Advocate have?

 

Every state calls the role something different, but there are programs that certify in each state. 

Generally, they are nurses or social workers, or have equivalent experience.

Licensing or certification is required for this role.

 

 

A Geriatric Care Manager is a position that you will have to pay for. Case managers that are paid by Medicare, the hospital or the insurance company will always represent those organization’s interest first, and yours afterward.

 

It is worth every penny to have someone in the trenches that is representing your best interests!

 

 

Online Tools when you are out of state from the patient:

 

 

ecarediary.com

reunioncare.com

 

These websites create a circle of care that allows everyone in that circle to have access to all the information and take action on different aspects of the care for the patient from where ever they are in the world.

 

 

 

 

Got questions about Patient Advocacy?

 

Karyn could assist in a consultative role if you are not located in FL. She can direct you to resources in your area.

 

 

Karyn can be reached:

 

By Phone: 727-452-1300 

 

By Email: info@agingguidebook1.com

 

Do you have questions or feedback? I’d love to hear it!

I may answer one of your questions on the air!

email me:

support@themedicarenation.com

Thank you for listening! If you enjoyed this podcast, please subscribe and leave a 5 star rating and review in iTunes! (Click here)    

Find out more information about Medicare on Diane Daniel’s website!

www.CallSamm.com

 

 

Apr 1, 2016

Welcome Medicare Nation! 

After last week’s show with Dr. Jeffrey Burns, I wanted to bring a guest on the show that could talk to us about her experience with the lack of care coordination with Medicare.

Melissa’s Mother fell and broke her hip before Christmas. At only 67, ended up having surgery and being in the hospital and then in a skilled nursing facility. At home she had outpatient therapy.

 

Melissa shares the following about her Mother’s experience:

 

  • She went to stay with her Mother during this time - she lived 4 hours away
  • She felt like she would just provide companionship and help her Mom get back on her feet
  • She quickly realized she would have to be a patient advocate for her Mother
  • She found out that the care for her Mom was good, but communication was terrible
  • She tried to follow up on her Mom's care on a daily basis, but it was overwhelming
  • Melissa wasn’t exactly sure of the medicine her Mother took on a daily basis
  • Melissa didn’t have all the information available about the Doctors that her Mom sees
  • Mom had an app on her cellphone that had all her medical info and also allowed her to call 911
  • Mom lived alone and fell late at night when she was in her garage
  • 1 in 3 people 65 and over will fall and a hip fracture is the #1 injury from that fall
  • She and her Mom text every night and every morning since her Mom lives alone
  • Surgery on the hip was successful, but there were some blood clots to deal with
  • Mom has a high tolerance for pain, but yet still seemed to be in a great deal of pain
  • Melissa found out that there was some miscommunication between the nurses and her Mom regarding pain meds
  • The hospital staff thought that Melissa's Mom had refused one of her pain medications
  • Actually Mom only questioned it because she thought she couldn’t have the 2 meds together
  • It wasn’t a refusal of medication, but her Mom just didn’t understand the issues and was confused
  • Constantly ask questions. Write them down as you remember them. Ask the questions to every staff member at every shift. 
  • Her Mom spent a week in the hospital before she went to rehab. It felt like they wanted to release her too soon.
  • The clinical coordinator for the hospital didn’t have a lot of information on placement options in a city 45 minutes away
  • They used the online site ratings through Medicare to find a skilled nursing facility
  • Minimum requirement is 3 overnight stays in the hospital to qualify to go to skilled nursing facility
  • medicare.gov has the resources to check ratings of skilled nursing facilities.
  • Private Institution ratings are not available on www.medicare.gov
  • Transportation to the skilled nursing facility, 45 minutes away, wasn’t handled by the hospital because the facility she was moving to was out of their "network."
  • The family had to arrange transportation through a private medical transportation service, where Mom could transported in her wheelchair.
  • In the skilled nursing facility, her Mom was there for 5 days before she even saw the nurse practitioner.
  • The physical therapist never actually showed up due to scheduling conflicts.
  • It’s important to find out the schedule that the Doctors will be keeping and seeing your family member and make sure you are there when they make the rounds.
  • Melissa found out that her Mom got confused about what meds she was taking for what ailments, so she wasn’t a help to sort things out.
  • Medicare allows Physicians to write prescriptions for home care therapy and it is provided at no cost to you. As long as a Dr. writes a prescription and the Physical Therapist is an approved Medicare provider and the patient can’t make it out to traditional therapy, it will be provided on most Medicare plans  free of charge.
  • Melissa was shocked at how important it was for her to be involved in her Mother’s care and recovery.
  • The outcome for Melissa’s Mom was good, but there were so many times along the way that could have gone terribly wrong, if Melissa wasn’t there to advocate for her Mom.
  • If you are not physically able to be with a family member during a crisis, you may need to inquire about hiring a Patient Advocate.

 

The Official Medicare website is a starting place for finding skilled nursing facility ratings.

Getting a patient advocate is a good idea if you aren’t prepared or able to assist your loved ones during a medical crisis.

 

Do you have questions or feedback? I’d love to hear it!

I may answer one of your questions on the air!

email me:

support@themedicarenation.com

Thank you for listening! If you enjoyed this podcast, please subscribe and leave a 5 star rating and review in iTunes! (Click here)    

Find out more information about Medicare on Diane Daniel’s website!

www.CallSamm.com

 

 

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