HEALTH CARE

MEDICARE      (Revised December 15, 2015)
 

Medicare is a federal health insurance program, administered by the Social Security Administration.  It was designed to help meet the medical expenses of people who are at least 65 year of age or disabled.  You can find a comprehensive discussion of Medicare in the federal government’s publication, “Medicare and You”. The 2016 version of the publication is available on the internet at: https://www.medicare.gov/medicare-and-you/medicare-and-you.html.   The Delaware Medicare Assistance Bureau (formerly "Elderinfo"), offers counseling about Medicare issues.  For information, visit the website at http://www.delawareinsurance.gov/DMAB or call 800-336-9500. 

Eligibility

1.   You are at least 65; or

2.   You are disabled and have been receiving Social Security disability benefits for 24 months; or

3.    You have ALS and have begun receiving disability benefits; or

4.   You are undergoing dialysis or need a kidney transplant because of permanent kidney damage.

Enrollment

Now that the age for full Social Security benefits is older than 65, enrollment in Medicare is automatic only for those who have elected to take their Social Security benefits early.   To enroll, contact your local Social Security office or go on-line at www.ssa.gov.  You can sign up for Medicare benefits as soon as three months before your 65th birthday and should sign up no later than three months after the month of that birthday.  Enrollment in Part B can be delayed if you or your spouse are employed by an employer that provides health insurance.  However,in order to avoid having a penalty imposed, you must enroll in Part B within eight months after you leave employment or otherwise lose benefits, whichever first occurs.

 
Coverage in Original Medicare

Part A:

Medically necessary hospital care;

If you have had a qualifying three day inpatient stay in a hospital prior to admission to the skilled nursing care facility, full coverage of twenty days of skilled care in a nursing home and 80 days of partial coverage; and

Temporary full-time or permanent intermittent home health care if you require some skilled care.  (Home health care is also covered under Part B).

The Part A premium is usually covered by the payments that you or your spouse made while employed. The Part A deductible for hospitalization varies from year to year but in 2017, the deductible will be $1,316 per period of illness. A subsequent hospitalization more than 60 days after discharge will result in a new period of illness and a new deductible. Co-payments are required for hospitalizations exceeding 60 days.

  Part B:

Part B covers doctor’s services, out-patient services, and medical supplies.  It pays 80% of the “reasonable charges” for covered services after a deductible has been satisfied.  Under the Patient Protection and Affordable Care Act of 2010 (2010 Health Act), effective January 1, 2011, preventive care is also to be covered under Part B without co-pays or deductibles.

You will usually have to pay a premium for Part B.  Medicare will send you a bill until you start receiving Social Security benefits.  After that the premium will be withheld from your benefit payment. 

The Medicare Part B premium and deductible vary from year to year.  In 2017, the premium for Part B will increased 0.3 per cent.  For beneficiaries who were previously grandfathered that is an increase from $104.90 per month to approximately $109.   For all others the Part B premium for 2017 will increase around 10 per cent from $121.80 to $134.00 per month. The part B deductible will be increasing to $183 per year.

The premium may be increased over the minimum, if your income is above certain limits.   However, you may be able to appeal an increased premium.

Whether a claim is under Part A or Part B, you should always receive a written notice from the Center for Medicare and Medicaid Services (CMS) telling you what Medicare has covered and what you may be responsible for.  Medicare generally forwards the information on to your supplemental insurance carrier (discussed below).  What is not covered by Medicare or your supplemental insurance is your responsibility.  If Medicare denies your claim you will have appeal rights that will be discussed in the Notice.

Supplemental Insurance

If you have original Medicare Parts A and B, you may wish to purchase a supplemental insurance policy, a “Medigap” plan.  The coverages of the different plans are defined by the federal government.  As of June 1, 2010, plans formerly designated E, H, I, and J are no longer be offered to new enrollees because they became unnecessary.  New plans K, L, M and N  were added. These newer plans have higher deductibles and/or co-pays and therefore premiums generally are lower.  Most Medigap policies cover the deductibles and co-pays not covered by Medicare Parts A and B, but the other benefits offered and premiums charged will vary from type of plan to type of plan.  You must determine what benefits are important to you.    Every company must offer Plan A but may choose which other plans it offers.  For a list of the companies offering Medigap plans in Delaware go to the Delaware Department of Insurance website: http://www.delawareinsurance.gov/divisions/DMAB

If you sign up for a Medigap policy within six months of the date that you first become eligible for Part B or within six months after you or your spouse is no longer employed and covered by employee insurance, the insurance company must accept you and cannot impose a waiting period because of a pre-existing condition.

Military retirees and eligible family members are eligible for the free program, Tricare for Life, which provides benefits that are quite similar to a Medigap plan. However, they might be required to enroll in Part B Medicare to maintain their VA health care. Moreover, Tricare does not cover emergency care in other countries.  For further information, you may go to the Tricare website:  www.tricare/mil/

Medicare Beneficiary Programs

Certain low income Social Security recipients can have their Medicare premiums, co-payments and deductibles paid by the State.  Delaware has no asset limits for these programs. 

Federal law requires that state Medicaid agencies pay the Part B Medicare premium, deductibles, and the 20% co-insurance expenses for financially-qualified individuals known as Qualified Medicare Beneficiaries (QMBs).  Thus Medicaid becomes the supplemental insurance for QMB’s. You may be a QMB if you are entitled to Medicare Part A and your income is at or below 100% of the Federal Poverty Level (FPL).  If you qualify, Medicaid also pays for the Part A Medicare premium, in the unlikely case that it is not free for you.  You should note that Medicare beneficiary programs do not provide any foreign coverage (including trips to Canada and Mexico) as there might be with a Medigap plan described above.

If your gross monthly income does not exceed 120% of the FPL, you are a Specified Low Income Medicare Beneficiary (SLMB), and Medicaid pays only your monthly Part B premium.  Finally, you might qualify for the Qualified Individual Program (QI) if your gross income does not exceed 135% of the FPL.  Although Medicaid also pays only your monthly Part B premium, the QI program differs from the SLMB program because it depends on reauthorization by Congress.  Note that SLMB and QI beneficiaries are still responsible for the 20% co-pays and deductibles.  Such individuals might consider signing up for a Medigap plan or a Medicare Health Plan discussed below.
To apply for a Medicare beneficiary program you must first apply for "Extra Help" as discussed below even though your asset level may disqualify you from help under that program.  Delaware does not count assets for the Medicare Beneficiary Program nor for the Prescription Assistance Program discussed below, but you are required to enroll in Extra Help if you qualify.
More information on the income thresholds and benefits is available on the Delaware State Website at: http://www.dhss.delaware.gov/dhss/dmma/qmb.html

Medicare Health (sometimes called "Advantage") Plans (Part C)

Medicare contracts with private insurance companies that sell what are sometimes called Medicare Health Plans or Medicare Advantage plans. Medicare Advantage Plans offer the benefits that otherwise would be offered by Medicare Parts A and B and a Medicare supplemental insurance plan discussed above and may include a prescription drug plan (Part D discussed below) – all in one plan.   Although you must have enrolled in both Part A and Part B to enroll in a Medicare Advantage plan, following enrollment, you will longer be enrolled in original Medicare.  Medicare Advantage Plans may include Health Maintenance Organizations (HMOs) (you must use affiliated doctors), Preferred Provider Organizations (PPOs) and private fee for service plans.  They are required to provide at least as many services as original Medicare.  All the Medicare Advantage Plans are listed on the Medicare www.medicare.gov) and the Delaware Insurance Commissioner (www.delawareinsurance.gov) websites.  The plans vary in their premiums and in how they provide coverage.  In most cases you will pay a premium each month as well as co-pays when you receive services.  You may be limited in your choice of physicians and other providers and if you travel outside the state or outside the country, you may want to confirm coverage or purchase travel health insurance.  If you sign up for a Medicare Advantage plan that offers prescription drug coverage, you must accept that coverage.  The 2010 Health Act made changes in the way in which Medicare Advantage companies are reimbursed but did not change the benefits offered.  Anyone signing up for a Medicare Advantage Plan should be aware that during the first twelve months, you can opt out and upon reenrollment in original Medicare, you will be entitled to subscribe to a Medicare Supplemental Insurance Plan regardless of the status of your health.  After that twelve month period, you switch Medicare Advantage plans during the annual open enrollment but you may only disenroll during the disenrollment period in January and February.  There is no guaranteed right to subscribe to a Medicare Supplemental Insurance Policy at that time.

Part D Prescription Drug Benefit

Part D Medicare is a voluntary prescription drug benefit provided by private insurance companies.  You are eligible for Part D if you are enrolled in either Part A or Part B Medicare.   You are subject to a penalty if you delay enrollment unless you have other prescription drug coverage that is at least as good as Part D, the so-called “creditable coverage.”  You must retain your “creditable coverage” letter to verify your coverage.  Since the penalty increases with every month you delay your enrollment and, after you enroll, is added to your monthly Part D premium for as long as you are a participant, the penalty can be extremely costly.  Most people can change plans only once a year, during the period between October 15 and December 7.

Effective January 1, 2011, Medicare beneficiaries with higher incomes may be subject to a monthly adjustment increasing their prescription drug plan premiums similar to the increase in Part B premiums discussed above..

In the standard prescription drug plan you pay a monthly premium and you may pay an annual deductible, In addition, you may pay a portion of the cost of the drugs until the total cost of the drugs, what you pay and what the insurance company has paid, total $3,310 in 2016. Then there is a coverage gap, sometimes called the “doughnut hole," until you personally have spent a total of $4,850 (in 2016). Your total expenditure includes your deductibles and co-pays prior to reaching the donut hole. After your total out of pocket expenditure reaches that $4,750 level, you will need to pay only the lesser of 5% of the cost of your drugs or $2.95 for generic drugs or $7.40 for other drugs. In January of the following year, the process starts again. As a result of the 2010 Health Act, the costs of drugs during the donut hole are discounted to a greater extent each year until the "doughnut hole" is eliminated in 2020. For more information, visit Medicare.gov The following is information for 2016: http://www.q1medicare.com/PartD-The-2016-Medicare-Part-D-Outlook.php  

There are many other prescription drug plans offered in Delaware.  Some have no deductibles or lower co-pays.  A few may offer some coverage of generics while you are in the "doughnut hole".  How drugs are priced differs from company to company. If you go to the Medicare web site (www.medicare.gov) you will be able to enter your current medications, dosages and favored pharmacy in order to locate plans that cover your drugs at the least annual cost.  You can also obtain counseling by contacting the Delaware Medicare Assistance Bureau at the Delaware Insurance Department, 800-336-9500.  Because enrollment in a prescription drug plan may cause you to lose employee benefits, it is vital that you contact your former employer’s human resources unit if you are covered by retiree health insurance before you enroll in a Part D plan. 

Extra Help With Prescription Costs -- Federal Low Income Subsidy – “Extra Help”

You may be entitled to extra help in paying for prescription drugs.  People who are entitled to both Medicare and Medicaid are automatically eligible for extra help and need not file an application.  Such people must belong to a prescription drug plan but they will not be responsible for premiums and deductibles and the co-pays will be reduced.  Anyone who does not qualify automatically but has assets (not including their residence, vehicle, burial plots, and insurance policy) below the limits will qualify for benefits under the Low Income Subsidy (LIS) program if their income is under 145% of the Federal Poverty Level and may qualify for benefits on a sliding scale if their income exceeds these amounts by a slight amount. 

The local Social Security Administration office can assist with applications for the LIS program or you may apply online through the Social Security Administration at: https://secure.ssa.gov/i1020/start   The government will send you a letter that requires you to verify your eligibility for the LIS program each year.  You MUST answer that letter to continue qualifying for extra help.  If you qualify for extra help, you can change your prescription drug plan as often as once a month.

Delaware Prescription Assistance Program

Under the Delaware Prescription Assistance Program, elderly or disabled individuals, with incomes under 200% of the Federal Poverty Guidelines or whose drug costs exceed 40% of their income, can qualify for up to $3,000 per year per person for medically necessary prescription drugs.  Clients pay 25% of the cost of the prescription or a minimum of $5.  You must be enrolled in the Social Security Extra Help Program if you are eligible.  To apply you mail a completed application and proof of income to the address on the form.  The form may be obtained by calling (800) 996-9969 or calling 211 and asking for the Delaware Prescription Assistance Program or on-line at: www.dhss.delaware.gov/dhss/dmma/dpap.html

MEDICAID

Medicaid is a combined state and federal program which primarily covers medical expenses for low income beneficiaries.  This Handbook will discuss only those benefits provided under the long-term care program.  The long-term care program provides benefits for individuals who receive care in nursing homes, or under the home and community or assisted living waiver programs.

There is a medical requirement for eligibility, which is that the applicant must have sufficient deficiencies in activities of daily living to require 24 hour care.  Under the home and community waiver, some of that care can be provided by family and loved ones.  The applicant must also meet asset and income limitations.

Asset Limitation:

  A single individual cannot have more than $2,000 in countable assets.  Assets that do not count include: personal belongings, a car, an irrevocable funeral arrangement, term life insurance, other life insurance with a face value of no more than $1,500, and a home (if the applicant resides there or intends to return).
If the applicant is married, the spouse remaining in the community is permitted to retain at least $25,000 in countable assets and may retain up to 50% of the couple’s total countable assets up to a maximum of $117,240 in 2014.  The community spouse’s solely-held retirement funds are unaffected.  The community spouse can also have an irrevocable funeral arrangement and keep the home as a residence.
An experienced Elder Law attorney can counsel families on preserving assets and qualifying for Medicaid under appropriate circumstances. Caution should be used in consulting with agencies or purported advisors who may not be qualified to give advice about this complicated area.

Income Limitation:

Delaware is what is called an “income cap state” and limits the applicant’s available income to $1,833 in 2014 (250% of the Supplemental Security Income (SSI) Level plus $20).  However, the limitation can be overcome by depositing the income into an irrevocable income trust commonly known as a “Miller Trust” and using the funds in the trust to pay the nursing home or other health care provider.  Miller Trusts are generally prepared by experienced Elder Law attorneys.  The community spouse is not required to contribute any income toward the care of the Medicaid beneficiary and may have his or her income supplemented by a share of the beneficiary’s income or retain additional assets to provide at least a living standard called the “minimum monthly maintenance needs allowance.”  From July 1, 2013 to June 30, 2014, this amount is $1,939. If certain basic household expenses are more than 30% of this amount, the community spouse may be entitled to keep extra income (called the Excess Shelter Amount) up to $2,931 (the Maximum Monthly Maintenance Needs Allowance) of the married couple's total income. If even more income is needed, the community spouse can request a fair hearing to attempt to prove the need for a higher amount.

Home Based Waiver Services

The Delaware Home & Community Based Waiver and Assisted Living Waiver Services are intended to allow the elderly and disabled to remain in their homes or in assisted living if they can do so safely with a package of services.  However, the cost of such services cannot exceed the cost of a nursing home.   Effective in April, 2012, all applications are handled by the Department of Medicaid & Medical Assistance (DMMA). More information is available at: www.dhss.delaware.gov/dhss/dmma/homeandc.html or you may call 866-940-8963.

NURSING HOMES and OTHER RESIDENTIAL FACILITIES

Nursing homes, assisted living homes, rest homes, and adult foster care homes are licensed in Delaware by the Division of Long-Term Care Residents Protection.  The website of the division is: www.dhss.delaware.gov/dhss/dltcrp .  Nursing homes which participate in Medicaid or Medicare must meet additional requirements in order to be certified under federal law to participate in those programs.
For a full list of licensed nursing homes in Delaware, visit: http://www.dhss.delaware.gov/dltcrp/licensednursinghomes.html
For a full list of licensed assisted living facilities in Delaware, visit: www.dhss.delaware.gov/dhss/dltcrp/assistedlivingfacilities.html
Lists of group, neighborhood and rest homes are also available from the Division of Long-Term Care Resident Protection and anyone with a complaint concerning a long term care facility should call the Division of Long-Term Care Resident Protection at (302) 577-6661 in New Castle County or (302) 424-8600 in Kent and Sussex Counties.

As with all contracts, you should read a long-term care facility contract before signing it.  The federal Nursing Home Reform Law prohibits a nursing home from requiring a third-party guarantee of payment as a condition of admission or continued stay.  Delaware law applies this prohibition to assisted living and rest homes as well.  Therefore, you cannot be required to guarantee the payment of your family member’s care out of your own funds.  Prior to admission, you should request a copy of the contract, review it thoroughly, and confer with an attorney to help you understand it.

Medicare may pay for part of your stay in a nursing home if you have been hospitalized for at least three days and you require daily skilled care.  If you qualify for Medicare coverage, it may pay all of the first 20 days and some of the next 80 days as long as you continue to need daily skilled care.  A nursing home is prohibited from requiring a deposit if your care may be covered by Medicare. Medicare does not pay for long term care.

Medicaid covers all expenses related to the resident’s care.  Medicaid is not insurance and is a welfare program of last resort. It does not cover certain personal needs (e.g. haircuts), but each Medicaid recipient receives a monthly needs allowance (2014: $44.00), which must be set aside for that individual.  If you are a veteran or a surviving spouse of a veteran, you may also be eligible for a VA benefit allowance (2014: $90.00 in a long-term care facility).  If you are receiving Medicaid benefits, your income pays part of the cost of care, and Medicaid pays the remainder.

ADVANCE HEALTH-CARE DIRECTIVE (LIVING WILL) - Revised January 14, 2017

Delaware authorizes an advance health-care directive (“the Directive”) which is a legal document that lets you name another individual or individuals as your “agent(s)” to make health-care decisions for you if you become incapable of making and communicating your own decisions.  It also allows you to communicate your wishes - ahead of time - regarding your care near the end of your life.  If desired, the Directive has provisions for you to make choices about being an organ donor.

Your agent will not have the authority to make any health-care decisions for you as long as you are capable and can communicate for yourself.  You always have the right to give instructions about your own health care, if you are able.  Your agent’s authority and the provisions of the Directive become effective only upon a determination that you lack capacity, and when the Directive is to be applied to the providing, withholding or withdrawal of a life-sustaining procedure, the Directive shall become effective only upon a determination that you lack capacity and have a "qualifying condition".

"Qualifying condition'' means you have 1 or more of the following conditions, certified in writing in your medical record by the attending physician and by at least one other physician who, when the condition in question is "permanently unconscious'' shall be a board-certified neurologist and/or neurosurgeon:

(1) "Permanently unconscious'' or "permanent unconsciousness'' means a medical condition that has existed for at least 4 weeks and that has been diagnosed in accordance with currently accepted medical standards and with reasonable medical certainty as total and irreversible loss of consciousness and capacity for interaction with the environment. The term includes, without limitation, a persistent vegetative state or irreversible coma.

(2) "Terminal condition'' means any disease, illness or condition sustained by any human being for which there is no reasonable medical expectation of recovery and which, as a medical probability, will result in the death of such human being regardless of the use or discontinuance of medical treatment implemented for the purpose of sustaining life or the life processes.

(3) " Serious illness or frailty" means a condition based on which the health-care practitioner would not be surprised if the patient died within the next year.

For a form of Directive that was developed and approved by the Elder Law Section of the Delaware Bar Association in January 2017, click here.  Unfortunately, the Section form of Directive is not available in Spanish as yet.  The Section form of Directive has three parts.  Part 1 is a power of attorney for health care.  You can name one or more persons as your agent(s) for health-care decisions and several alternates, if the primary person(s) you designate is unable to serve or is not available.  This part allows the agent to obtain medical information about you under the Health Insurance Portability and Accountability Act, generally referred to as HIPAA.  Part 2 provides you with the ability to give specific instructions regarding whether or not you wish to receive life-sustaining medical measures if you are ever declared “terminally ill,”  “permanently unconscious” or suffering from a "serious illness or frailty.".  Before deciding on your specific instructions, you may want to consult with a doctor for guidance.  Part 3 lets you express an intention to donate your body, organs and/or tissues following your death, if you so choose.
Another form of Directive can be obtained from the Division for Services for Aging and Adults with Physical Disabilities by calling 1-800-223-9074 or writing to the Division at 1901 North DuPont Highway, New Castle, Delaware 19720 or downloading a printable version from the Division’s website at: http://www.dhss.delaware.gov/dsaapd/files/advancedirective.pdf.  The “Division of Aging Directive” is valid, but it is not as flexible in the naming of agents nor in the extent of listing of options under instructions for end-of-life decisions as the Section Form of Directive.

Every form of a Directive must be signed by the person making the Directive, the “declarant”, in the presence of two qualified witnesses, who also sign the Directive.  To be qualified the witnesses:

1.   Cannot be related to the declarant by blood, marriage, or adoption;

2.  Cannot be entitled to any portion of the estate of the declarant under any will of the declarant or codicil thereto then existing nor, at the time of the executing of the advance health-care directive, be so entitled by operation of law then existing;

3.  Cannot have, at the time of the execution of the advance health-care directive, a present or inchoate claim against any portion of the estate of the declarant;

4.  Cannot have a direct financial responsibility for the declarant’s medical care;

5.  Cannot have a controlling interest in or is an operator or an employee of a health-care institution in which the declarant is a patient or resident; or

6.  Cannot be under eighteen years of age.

The declarant, if mentally competent, may revoke all or part of the Directive by a signed writing or may revoke all or part of the Directive in any manner that communicates an intent to revoke in the presence of two competent witnesses, one of whom is a health-care provider.

A Directive cannot be given effect unless someone knows it exists.  If you make a Directive, tell about its location to, and/or provide copies to, those people who would be involved (e.g., family members and doctors).  Your wishes cannot be followed unless your health care providers know about them.  If you executed a living will before July 12, 1982, it probably does not comply with the current Delaware law and you should execute a new Directive.  If you executed a living will before June 26, 1996, it may be limited to a terminal condition and may not direct what you want in the event you are permanently unconscious as allowed under the current Delaware statute.  You may wish to execute a new Directive.  You should have an executed Directive before you enter a hospital or long term care facility, although the hospital or long term care facility may not require you have a Directive in order to be considered for admission.
If you find the language of the Section Form of Directive or the Division of Aging Directive too limited, you may execute a separate Medical Power of Attorney with provisions particular to your wishes.  If you do want something more than what those Directives provide, then consultation with your doctor about procedures and consultation with an attorney about the drafting of the Medical Power of Attorney is recommended. 

If You Have Not Executed An Advance Health-Care Directive If an adult patient does not have a Directive, Medical Power of Attorney, or court-approved guardian, or if the Directive does not address the specific issue, a surrogate may make a health care decision to treat an adult patient if the patient has been determined by the attending physician to lack capacity.  This determination of a lack of capacity shall be confirmed in writing in the patient's medical record by the attending physician. The surrogate may also order the withdrawal of life sustaining treatment if the patient has a requisite "qualifying condition" discussed above.  A surrogate is selected in the following order of preference:

1. A spouse, unless a petition for a divorce has been filed, or unless the patient has filed a petition or complaint alleging abuse of the patient by the spouse.

2. An adult child.

3. A parent.

4. An adult brother or sister.

5. An adult grandchild.

If none of the individuals listed above are eligible to act as a surrogate or are reasonably available, an adult who has exhibited special care or concern for the patient, who is familiar with the patient’s personal values, and who is reasonably available may make health-care decisions as a surrogate if appointed as a guardian for the purpose by the Court of Chancery.

Delaware Medical Order for Life Sustaining Treatment (DMOST)(Added January 12, 2016 & revised November 23, 2016)

Beginning on April 1, 2016, DMOST, a new form of medical order, is available for patients whose health-care practitioners would not be surprised if the patient died in the next year. The form is voluntary and cannot be required for admission to a health-care facility. DMOST is a single document that will function as an actionable medical order and transition with a patient through all health-care settings. To create a DMOST, the patient (and if the patient desires, anyone the patient wishes to be present) will meet with a health-care practitioner to discuss the patient's wishes for treatment and those wishes will be then documented on the DMOST form which is then signed by the health-care practitioner and the patient. The DMOST form can be completed by any licensed physician or by an advance practice registered nurse or physician's assistant if those providers have taken the training required by the statute and regulations. If the patient lacks decisional capacity, a legally authorized agent or guardian may meet with the health-care practitioner to complete the DMOST form. The law requires any health-care provider to honor the DMOST form, if the patient is unable to communicate. The DMOST is not intended to replace the Directive but rather to supplement it, except that there is a section of the DMOST, which when signed by the patient, will limit the ability of an agent for health-care to alter the DMOST. For a pdf version of the DMOST form, go to:  http://regulations.delaware.gov/register/january2016/final/4304%20DMOST%20Form.pdf.  The regulations can be found at:  http://regulations.delaware.gov/AdminCode/title16/Department%20of%20Health%20and%20Social%20Services/Division%20of%20Public%20Health/Emergency%20Medical%20Services%20(EMS)/4304.shtml