By Lauren Rabin
Maybe you are like me and over the age of 60 and starting to think about your retirement years or have a family member already in retirement that needs medical care. Last year my mom progressed to a point where she needs long term skilled nursing and that is when my siblings and I had a crash course in Medicare and Medicaid.
Medicare is a federal health insurance program for people aged 65 or older, certain people under 65 with disabilities and people of any age with end stage renal disease (ESRD).
The Centers for Medicare and Medicaid Services (CMS) manages the Medicare program. There are distinct parts to Medicare. Social Security takes applications to enroll people in Parts A & B.
• Part A (Hospital Insurance) helps pay for inpatient care in a hospital for a limited time at a skilled nursing facility (following a hospital stay). Part A also pays for some home health care and hospice care.
• Part B (Medical Insurance) helps pay for services from doctors and other health care providers, outpatient care, home health care, durable medical equipment, and some preventative services.
Private Insurance companies take applications for and provide coverage under Part C (Medicare Advantage), Part D (Prescription Drug Coverage) and Medicare Supplemental Insurance Program (Medigap).
• Part C (Medicare Advantage) is a “bundled” plan offered by Medicare-approved private companies that includes all the benefits and services under Parts A and B, usually Part D and may include additional benefits such as vision, hearing and dental.
• Part D (Prescription Drug Coverage) helps cover the cost of prescription drugs and many shots and vaccines.
• Medicare Supplemental Insurance Program (Medigap) is extra insurance you buy from a private company that helps pay your share of costs in Original Medicare.
Late enrollment in Medicare B and D carries penalties that are cumulative and for the life of the applicant. The State of Connecticut offers financial assistance to eligible Medicare enrollees through the “Medicare Savings Programs.” These programs may help pay Medicare Part B premiums, deductibles, and co-insurance. Medicaid funds Medicare Savings Programs.
Clear as mud? We are so fortunate that Greenwich’s Commission on Aging administers Medicare & Health Insurance Counseling. See www.greenwichct.gov/190/commission-on-aging for more information.
Since Medicare does not pay for long term skilled nursing. We learned there are choices:
• Self-fund: According to the State of CT Office of Policy and Management, as of Sept 2020, the average daily cost of a semi-private room in CT is $456, or $166,400 annually.
• Possess Long Term Care Insurance: The cost of long-term care insurance is not cheap. A 55-year-old man in the US can expect to pay an annual long-term care insurance premium of $2,220 on average, according to a 2022 price index survey conducted by the American Association for Long-Term Care Insurance. 55-year-old women can expect to pay an annual premium of $3,700 on average because we tend to live longer.
• Qualify for Medicaid: Medicaid is a federal program that is operated by the States, and each State decides who is eligible and the scope of health services offered. The Medicaid programs in Connecticut are HUSKY A, HUSKY C and HUSKY D.
There are three categories of Medicaid long-term care programs for which CT seniors may be eligible.
1) Institutional / Nursing Home Medicaid – This is an entitlement program; anyone who meets the requirements will receive assistance. Benefits are provided only in nursing home facilities.
2) Medicaid Waivers / Home and Community Based Services (HCBS) – These are not entitlement programs; there are a limited number of participant enrollment slots and waiting lists may exist. Intended to delay the need for nursing home care, benefits are provided at home, adult day care, adult foster care homes, or assisted living residences.
3) Regular Medicaid / Aged Blind and Disabled – This is an entitlement program; anyone who meets the eligibility requirements can receive services. Limited long-term care services, such as personal care assistance or adult day care, may be available.
Medicaid long-term care programs have varying financial and medical eligibility criteria. Further complicating eligibility are the facts that the financial requirements change annually, vary with marital status, and that Connecticut offers multiple pathways towards Medicaid eligibility. A single individual applying for Nursing Home Medicaid in 2023 in CT must meet the following criteria: 1) Have income under the cost of nursing home care 2) Have assets under $1,600 3) Require the level of care provided in a nursing home facility.
For Connecticut residents aged 65 and over who do not meet the eligibility requirements above, there are other ways to qualify for Medicaid.
1) Medically Needy Pathway – Connecticut has a Medical Spend-Down Program for seniors who have income over Medicaid’s income limit. This program allows them to become income-eligible by spending the majority of their income on medical bills, such as private health insurance, unpaid medical bills, and medical expenses that Medicaid does not cover.
2) Pooled Income Trusts – Disabled seniors in CT applying for a Medicaid Waiver who have income over the limit can become income-eligible by depositing their “excess” income into a Pooled Income Trust. This option can eliminate one’s need to “spend down” income, as discussed above.
3) Asset Spend Down – Persons who have assets over Medicaid’s limit can still qualify for Medicaid by “spending down” extra assets. This is done by spending countable assets on non-countable ones. Examples include addition of wheelchair ramps, prepaying funeral, and burial expenses, and paying off debt.
4) Medicaid Planning – The majority of people considering Medicaid are over the income limit, the asset limit, or both limits, yet they still cannot afford their cost of care. For these people, Medicaid Planning exists.
Here is to living long and healthy!
Selectwoman for the Town of Greenwich. Daughter, Sister, Wife, Mother and Grandmother.
