This time of year could try any senior’s soul. Between Oct. 15 and Dec. 7, adults 65 and up who are eligible for Medicare can switch from one health plan to another without penalty.
During this open enrollment period, seniors are deluged by TV ads, letter campaigns and e-mail messages encouraging them to switch medical plans.

The reason? During this time, if you are not completely satisfied with your current plan—or if your health needs have changed—you can look for a plan that better meets your needs. This also is also the time when you can switch from one prescription drug plan to another without complications.
Below are a few explanations that may clarify some of these terms:

Medicare. This is a federal program that pays for certain health care expenses for people aged 65 or older, and for some younger people who meet special criteria. Medicare Part A covers hospitalization and nursing home care. Medicare Part B covers doctor visits, outpatient medical procedures, and some medical tests. The special enrollment period allows you to change your type B coverage, although your decision could impact your hospital or nursing homes coverage as well.

Medicare Part B. This is also referred to as Original Medicare. This program requires you to pay a monthly premium of $104.90, and an annual deductible of $147. After these costs are met, Medicare B will cover 80 percent of most medical exams and procedures; you or yet another health plan must pay the rest. Part B coverage includes most preventative-care services, annual physicals, depression screening, HIV screening, mammograms, prostate cancer screening, flu shots and diabetes tests.

Medicare Part B also covers most medical equipment, home health care, outpatient physical, occupational and speech therapy, outpatient mental care services and emergency transportation.
It is important to note that Medicare Part B does NOT cover most dental care, eye exams, hearing aids, alternative medicine and cosmetic surgery. It also does not cover prescription drugs. Many of these services can be added to your care by applying for a Medicare Supplemental Insurance plan, often called a Medigap plan.

Medigap plans. These are private health insurance plans designed to supplement Medicare. They cover such costs as copayments, coinsurance and annual deductibles. The names of some Medigap plans are: AARP Medical Supplement, Humana Medical Supplement and Emblem Health Medical Supplement. Their costs and coverage vary, depending on what they offer, but enrolling in one of these plans will provide you with the 20 percent payment not covered by Medicare—and may also provide additional coverage of such services as vision, hearing and dental care. Every Medigap policy must be clearly identified as “Medicare Supplement Insurance.”

Medicare Part C (Medicare Advantage) plans. These plans are administered by private companies that are approved and regulated by the federal government’s Centers for Medicare and Medicaid Services (CMS). The emphasis here is on “private.” They are plans that the government contracts; they offer policies that cover doctor visits, hospitalization and, sometimes, prescription medication. Medicare Advantage plans must offer benefits on par with traditional Medicare, but many providers include more as a way to attract customers. Some of these services may include vision, hearing and dental care. The most common types of Medicare Advantage include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and Private Fee-For-Service (PFFS) plans.

Medicare Advantage plans require you to pay the same monthly premium you would pay for Medicare Part B. Many include additional services under this fee, while other plans offer “tiers” of service at varying cost levels. Some even include gym or health club memberships. In exchange for these extra benefits, these plans may require that you adhere to a limited “network” of providers. If you decide to purchase a Medicare Advantage Plan, find out what additional services are actually included before signing up. A plan that includes vision care, for example, may only reimburse an annual eye exam, but not glasses. Remember that you will rarely get more from a similarly priced program without giving up other benefits.

Medicare Part D. This is the prescription drug program. Private pharmaceutical companies approved and regulated by the federal government provide Medicare Part D plans. These programs require payment of monthly premiums ranging from $15 to $165, plus small co-payments for each drug. People who enroll in traditional Medicare must also select a Medicare Part D prescription program. Many Medicare Advantage plans include a drug plan or plans. If not, you must select one as well.

Before you switch plans, it’s important to evaluate your needs.

8 Questions to ask before changing health plans

How much will I have to pay for premiums, deductibles, doctor visits or hospital stays?

Are all the services I need covered under this plan? If not, is there a way to obtain coverage without paying large additional amounts?

Are my doctors in this plan? If not, can I continue to see an “out of network doctor” even if it costs a bit more?

What services will I give up if I switch plans?

Will I have to choose my hospital and health care providers from a limited network?

Are the hospitals/nursing facilities in my network convenient to me? Do they have good ratings?

Will I need physician referrals to visit specialists?

Are my prescription drugs on the plan’s formulary? What is my prescription medication copayment?

Does the plan I selected have a good quality rating?

Joanna Leefer is an eldercare advisor with 10 years experience working with aging issues. She was the primary caregiver for her parents for over seven years and worked for FRIA Inc. (Friends and Relatives of Institutionalized Aged) an advocacy organization for the elderly. For more information on her services, log onto www.joannaleefer.com. Her book Eldercare Basics will be available in spring 2013.

Alan Chartock. Photo courtesy of wamc.org.

To understand what he did and why he did it, you have to understand the realities of elections. Since about half the eligible people don’t bother to vote in presidential elections, the name of the game is to get your voters to turn out. When Romney chose Ryan he was offering a huge incentive for conservative Republicans to get out and vote. He was lighting a fire under their behinds. That’s the way elections are won or lost.

The Romney problem is that there are more Democrats and independents in the United States than there are conservative Republicans. Romney’s vice presidential choice will light an even bigger fire under the keisters of the Democrats and independents who do not want to lose Social Security as we know it or the highly popular Medicare program. Ryan is death on both of these programs.

There may be a lot of people who don’t like what the Republicans are calling “Obamacare,” but just ask any senior or anyone who just can’t wait to get to Medicare, what they think of the incredibly popular senior medical program; or ask seniors (or their appreciative children) what they think of Social Security.

I remember my late mother’s appreciation for her Social Security check. My mom had worked all her life putting money into Social Security. I admit that my mother hated most Republicans but the thought of losing Social Security or of the Republicans trying to “modify” Roosevelt’s signature program by handing it over to the Wall Street crowd to get their hands on the highly efficient program would have brought this liberal lady out onto the streets. By threatening Social Security and Medicare, Romney has given the Democrats the gift of life. No matter what he says to save the day, the words and actions of Ryan will prove to be fatal to Romney. In fact, Romney has committed political suicide by choosing Ryan.

Finally, there is Medicaid, a program designed primarily to help the poor and elderly who have no other place to turn. When those often non-voting poor realize that their health care is being threatened by the draconian Ryan, they will have a good reason to vote. As we saw, not that long ago in Florida, just a few votes can swing an election.

In New York, the Democrats should be celebrating. The New York state Senate is up for grabs and if the lower-income voters turn out, it is inevitable that they will vote for Democratic candidates down the line. Democrat Andrew Cuomo has given Dean Skelos and the Republican Senate majority every break. He didn’t veto their self-serving gerrymander bill as he promised he would. I am old enough to remember the Democratic landslide in Goldwater-Johnson in which all kids of Republicans got thrown out in New York.

To turn this election in their favor, you had better believe that the Democrats are going to plaster the television airwaves with Ryan’s picture and what he wants to do with two of the most popular social programs in American history. You’ll see crying babies and seniors threatened with eviction. When I explained how this was going to work to some elderly friends, one of them said, “You don’t have to worry, it will only be younger people who will lose these benefits.” In response, I said, “These younger folks have been putting money into these programs for years. They are looking forward to Social Security and Medicare. They are going to be very angry when and if all of this comes down.”

Poor Mitt Romney; he may be good at making a lot of money. That doesn’t make him smart. He’s just committed political hara-kiri. In New York, he’s probably the best thing the usually hapless Democrats have going for them.

Alan S. Chartock is president and CEO of WAMC/Northeast Public Radio and an executive publisher at The Legislative Gazette.

Photos Courtesy of Alissa Fleck

A number of groups and individuals met today in Foley Square to rally in support of SCOTUS upholding the Affordable Care Act (ACA). Health Care for All New York organized a “Rally to Respond” to the ruling, which was quickly retitled a “Rally to Celebrate,” announced Director Mark Hannay to the crowd. Hannay was among several speakers—doctors, advocates and elected officials—addressing the jubilant crowd of community supporters at the evening rally.

(by Alissa Fleck)

Hannay called the ruling a “milestone step forward in the history of justice,” pointing to the Declaration of Independence’s insistence on the right to life, liberty and the pursuit of happiness. Hannay said these rights cannot be met without affordable, accessible healthcare for all.

Hannay added SCOTUS making healthcare a right for all means America is finally moving toward other industrialized nations, though he said we are only “9/10ths of the way down the field” and must continue to politically support those who uphold affordable healthcare.

Other speakers laid out the main points of what the ruling would mean for Americans, and New Yorkers in particular, including a breakdown of what could be expected by 2014. State Assemblyman Richard Gottfried explained the ACA would help make health funding available for working families, encourage providers to communicate with one another and ensure senior citizens can afford necessary drugs among numerous other modifications. Preventive care will become more widely accessible, particularly pertinent to many women’s health issues.

Georgetown law student and women’s rights advocate Sandra Fluke took the stand to applaud the efforts of Americans who worked to support the SCOTUS decision as well as to remind crowd members the fight is not over.

“I don’t want to see ideologically-driven legislators work to repeal this decision so they can say they fought Obamacare,” said Fluke. “We want the implementation of the whole Affordable Health Care Act and we want it now.”

All the speakers agreed this decision, while important, is foundational and there are still hurdles from here, including building on decisions made in Washington to make laws in New York “even better” and make health care “a right, not a privilege.”

Speaker Quinn called what happened in Washington an “incredibly American act” and said the days of no options for many sick people and “whether you could get treatment [meaning] how big your paycheck was” are coming to an end.

“All have the right to get well, be well and stay well,” said Quinn. “Let’s make it even better.”

Myth: I cannot become eligible for Medicaid because my assets are too high.
Fact: Applicants for Community Medicaid in New York State must have less than $14,250 (for a single person) or $20,850 (combined assets for a married couple).
An applicant’s residence does not count as an asset if the market value of the home, minus the amount mortgaged, is less than $750,000.
Applicants with assets higher than the Medicaid limit can reduce them by spending them down to the limit or by transferring them to a trusted family member or an irrevocable trust. If you have significant assets, you should consult with an elder care attorney about how best to reduce them.
Once you have reduced your assets to under the limit, you are eligible to apply for Medicaid in the following month.

(By Roy Herndon Smith)

Myth: I cannot get Medicaid because my income is too high.

Fact: The Community Medicaid income limits are $792 a month for a single person and $1,159 for a married person.
You can still apply and qualify for Medicaid if you have income over these limits. Medicaid treats such “surplus” or “excess” income as a deductible. For instance, if you are a single person with an income of $1,292 a month, you have a surplus of $500. If you have $1,400 of medical expenses, including home care, in a month, Medicaid will only pay for $900 of those expenses; you will be billed for $500.
However, you can use a pooled income trust to protect your surplus income. Once Medicaid recognizes that you are disabled and are depositing your surplus into a pooled income trust, it will pay for all the covered medical expenses, including home care. You will not be billed for the surplus amount. You can have the trust use almost the entire surplus to pay for your regular bills, such as rent and utilities.

New York City’s Human Resources Administration can take a long time, sometimes over 3 months, to approve Medicaid and Medicaid home care. Applicants, especially when they have surplus income and are using a pooled income trust, often face delays and difficulties and need expert help to deal with them. For these reasons, if you foresee needing Medicaid to pay for home care in the future, you should start preparing to apply now by calling a knowledgeable geriatric care manager or social worker.

Roy Herndon Smith, Ph.D., is with Community Geriatric Care (communitygeriatriccare@gmail.com), a subsidiary of Foremost Home Care.

“Susan” was burned out. Nine months earlier, she had taken what she thought would be a temporary leave of absence from her job to care for her 85-year-old mother, who was recuperating from surgery after falling and breaking her hip.

Her mother never fully recovered. She still needed help with bathing, dressing, cooking, cleaning and almost everything else. In the last couple of months, she had become forgetful and confused. She neglected paying her bills, and Susan had to take over managing the checkbook.

Susan found that she was spending almost all of her time taking care of her mother. She was close to using up her savings. She hadn’t spent an evening with a friend or visited her daughter, son-in-law or grandson for over six months. She was lonely, exhausted, scared and often angry. She wasn’t sleeping well. Her back was bothering her. She seemed to catch every virus that was going around.

“Susan” is a composite case, but her suffering is similar to that of many of the family members, companions and friends caring for disabled loved ones with whom we have worked over the last decade. Stress, isolation, impoverishment, exhaustion, increased vulnerability to illness and injury are too often the costs of such care.

Securing the services of a professional home health or personal care aide is usually the single most effective way of alleviating caregiver burnout. Often, an aide allows the caregiver to get some rest, return to work, visit other family members and have a social life.

You can secure the services of an aide by calling a licensed or certified home care agency. Long-term care insurance will usually pay for home care. Medicare and other health insurance programs will sometimes pay for limited amounts of home care.

Medicaid will pay for home care. If your loved one’s income or assets are above the financial limits, a knowledgeable social worker, geriatric care manager or elder care attorney, in most cases, can show you legal ways to reduce assets and shelter “surplus” income to receive full Medicaid benefits.

Roy Herndon Smith is with Community Geriatric Care Management, a subsidiary of Foremost Home Care.

Susan Braudy’s photo and prior columns suggest that she is not old enough to be enrolled in Medicare. I assume, therefore, that her first-person column “Fired By My Doctor” (June 10) is literary license and that her statements are based on journalistic research. However, she has not been fair. She gives only one perspective.

First, let me state that although I am a retired primary care physician, my entire career was as a salaried employee of a non-profit organization. Thus, I never had to worry about Medicare or insurer fees—or any fee for service—income.

But I would like to comment on the physician’s side of the story, which applies not only to Medicare, but to many other insurance reimbursements. There are many reasons why physicians object to and decline to accept various insurance reimbursements. I base my comments, which follow, on my reading of medical articles, discussions with other physicians and personal opinion.

• Many fees are less than the cost of operating a practice. I just read Losing My Patience, by Mickey Lebowitz, M.D., who left private practice for a salaried position because income, largely from insurance fees, did not enable him to meet his expenses. If Medicare fees are indeed less than that of other insurers, and Lebowitz could not make ends meet with the relatively higher fees, how can one expect physicians to make ends meet with the relatively lower Medicare fees?

• Medicare fees can be unpredictable as the fiscal year progresses, although I believe Congress has always stepped in at the last moment to prevent this. In theory at least, a Medicare budget is set using fees based on the predicted total and combination of services. To maintain budget neutrality, Medicare may reduce fees toward the end of the year if the rate of expenditure is greater than predicted.

• Although most insurance fees may be higher than Medicare fees, some managed care insurance fees are lower than Medicare fees; a factual error in Ms. Braudy’s column.

• If one can exclude the emotions related to health and healthcare, as well as the tradition which has tended to make healthcare a right, is it fair for physicians be the only professionals whose service value is dictated or controlled by others, rather than by supply and demand? Our Constitution and laws guarantee us legal rights; however, there is no control of attorney fees in order to provide similar access to legal care. If one cannot afford the high-priced attorney, then tough luck.

• Is it really fair to control or cap the income of one group of individuals while not controlling their expenses? To the best of my knowledge, the only other situation in which this occurs is rent control/stabilization—another emotionally charged issue.

• Physicians typically spend seven or eight years (and more in some cases) training beyond college, while attorneys spend three or maybe four years. When one considers these costs, which include forgone income, why shouldn’t physicians be reimbursed at the same rate as attorneys? My attorney charges $400/hour and his overhead is less than that of a typical physician. In addition to very costly professional liability insurance for the physician versus the attorney, supply costs for the physician undoubtedly far exceed that for the attorney. Both have the expense of utilities, paper, etc., but physicians use a considerable amount of disposable equipment, such as dressing gowns, needles, syringes, tongue depressors, etc.

• Physicians’ fees should also be higher to compensate for services (time) that is not considered reimbursable, but for which attorneys would charge. Fees paid to physicians do not compensate for services that do not involve direct face-to-face contact. These services are phone conversations, record reviews, calls to pharmacies, discussion with consultants, etc. Attorneys, on the other hand, typically charge for these services. An attorney once billed me for time spent researching the law and consulting with his partners. A physician, on the other hand, cannot charge for time spent researching a case-related matter of therapy.

• Is it fair that starting salaries for recent graduates with MBAs (perhaps two years of schooling beyond college) in law, finance and information technology exceed by far starting salaries for starting physicians, with seven or more years of post-college training? These other professions’ salaries equal and often exceed the income of established physicians at the peak of their careers.n

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Seymour Herschberg, M.D., is certified in internal medicine and geriatric medicine, and received a certificate of advanced achievements in internal medicine in 1987. He is based on West End Avenue.

By Susan Braudy

A poisonous cloud hovers. The literally sickening gap between the very rich and the rest of us in New York City is widening as you read this sentence. I am singularly blessed with a rich, generous brother—who’s been there for me in a medical pinch. Otherwise, my health and life span might have been compromised.

It turns out that many of the best, snootiest New York doctors are refusing to settle for Medicare fees, dangerously widening the healthcare gap. Several of our finest so-called caregivers fired me when I joined Medicare because they said the fees that Medicare pays just weren’t high enough.

Why can’t the government make it illegal for rich doctors to either fire or insist on full fees from Medicare patients? This feels so cold-hearted for patients, such as myself, who’ve been cared for by these doctors for years.

The mess isn’t as sickening as the hordes of doctors opting out of Medicaid, a tragic story that hit the front page of the New York Times, but it’s pretty icky.

Dr. Carlin Vickery was the first doctor to present the bewildering Medicare facts to me in her orchid-decorated upper Fifth Avenue office. She simply charges much more than Medicare would reimburse her. Some of our finest doctors—indeed the finest on earth, such as breast surgeon Alisan Goldfarb—have not opted out of Medicare. But Dr. Goldfarb’s an exception; her Medicare fee is 10 percent of her normal operating fee. Another hero is my world-class cardiologist Dr. Martin Post, who diagnosed a symptom-free David Letterman as having a dangerously weak heart. (“He has a seventh sense,” says my neighbor Mara Gardner. “He senses the heart.”)

I know the sad story backward and forward. For the past decade at least, Medicare has reduced fees to shrinks, for example, by 5 percent a year, refusing to consider advancing inflation and rents. This year, Congress voted to reduce fees by 23 percent, then put the decision on hold. Dr. Ann Dolinsky, a superb psychiatrist, is the only one I know who has not terminated her Medicare patients.

I don’t know whom to blame. But holy smokes, I’m scared.

I think New York magazine’s list of best doctors should note whether they take Medicare. The latest doctor to opt out on me is Dr. Miriam Levy, of Medical Imaging of Manhattan, who I’m told is the best in the business. If I want a bone density scan from her office, which I’ve patronized for two decades, I must pony up $400 (loyalty is not an issue). I must say I’ve noticed a certain parsimony and indifference to patients’ time in the way this office is run. I’ve sat three hours waiting. The reason, I was told, is to insure that machines and technicians are used as much as possible.

Dr. Jesse Rosenthal, psychopharmacologist, announced that he’d fire me when I reached Medicare age. He told another doctor he doesn’t like treating older people. Dr. Andrew Martorella, an endocrinologist, is one doctor I continued to see for a year after he suddenly decided to refuse Medicare insurance.

Why the hell can’t the government’s Medicare insurance match insurance payments from private companies? Another solution: Why can’t Congress at least set up a sliding scale of payment, based perhaps on patient income, allowing patients to reimburse doctors and to at least match fees paid by private insurers, thus compensating doctors a bit better for their vital work? Will the government’s new healthcare plan pay too little for many doctors as well? Help! n

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Susan Braudy is the author and journalist whose last book, Family Circle: The Boudins and the Aristocracy of the Left, was nominated for a Pulitzer by publisher Alfred Knopf.

A: Long-term care insurance is custodial care insurance. It covers care generally not covered by health insurance or Medicare insurance. Long-term care insurance generally covers home care, assisted living, adult day care, respite care, hospital care, nursing homes and Alzheimer’s facilities. When home care coverage is purchased, long-term care insurance pays for home care from day one. It will also pay for a visiting or live-in caregiver, companions, housekeepers, therapists or private duty nurse.

Why should you consider long-term care insurance? If you have assets to protect and you want to leave these assets to your children or other family members, it’s a good insurance to have. Your medical insurance or Medicare insurance will not cover custodial care. If you have assets, you must pay out of your own pocket for the care. When you have spent down to your last $3,500, then you will qualify for Medicaid. At this point, you will not have much choice in the type of care you are given, or where the care is given.

You will qualify for benefits when you need substantial assistance with at least two of the six activities of daily living. They are bathing, eating, dressing, toileting, continence and transferring (getting in and out of bed, the shower, etc.). In addition, it is expected that you will need substantial assistance for at least 90 days, or you need supervision because you have a severe cognitive impairment. Your own doctor, nurse, licensed social worker certifies from time to time that you need the supervision.

The cost of long-term care insurance basically depends on your age, the amount of daily or monthly insurance you want, the elimination period (the amount of time before your benefits go into effect) and any options you may select. Naturally, the younger you are, the lower the premium.

Long-term care insurance premiums are tax deductions in your federal and New York State and City tax returns. The premiums can save you tax dollars. You may think that the cost of the insurance is high, or that you will never need it, but it is a great way to protect your assets because nursing home stays in New York City are about $15,000 per month.
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Gary E. Reska offers individual and business taxes, and complete bookkeeping and business forms service. Contact him at 212-249-2525 or gary@garyreskatax.com.