A Brief Rant about Medicare and Medicaid

Charles Atkins & Lisa Hoffman

Published 11/18/2004

-An ounce of Prevention is worth a Pound of Cure-


"It makes no sense," Lisa starts, "they’re taking away two mornings of my aide, because they say my condition has gone from acute to chronic and Medicare doesn’t pay for people who have chronic conditions. I still need someone to help me get dressed and bathed."

"What are you going to do?" I ask.

"Well, I’m again calling the Center for Medicare Advocacy, because this doesn’t seem right, somehow. I still need these services. And I’m already paying for 13 hours a week of aides. Now, if I was poor they tell me that I could get an aide through Medicaid, and if I was rich, paying for an aide out-of-pocket wouldn’t be a hardship. But I’m not rich; I have to watch my money. It doesn’t make sense. The attorney I called said it’s my doctor who makes the final decision, but there seems to be a lot of pressure to cut back my services."

"Well," I say, "Medicare has many rules and policies that tend to scare doctors and others, because if you don’t follow them, you can get into a whole lot of trouble, and be accused of Medicare fraud and abuse."

"I don’t know about that," she says, "but it seems that the few dollars they save on taking away necessary services, they may have to pay should something bad happen, and I have an accident—God forbid—and land back in the nursing home. Isn’t prevention a more-practical approach?"

"Of course, but that’s not how the system is set up. Almost none of it focuses on prevention. It’s a patchwork between Medicare, Medicaid and what families and individuals are able to scrape together on their own. Like you, there are a lot of people with disabilities who could probably remain in their own homes—which is what most folks prefer—with the assistance of an aide to help them in the morning and before bedtime. But Medicare won’t pay for that in an ongoing way. Yet, if someone becomes impoverished—because you can’t have assets of more than $1600 plus a burial plan--you can get on Medicaid/Title 19, which will pay for a nursing home that is far-more expensive, and far-less desirable."

At which point we scurry for the telephone to get quotes on nursing homes. We start with the director of the Lutheran Home in Southbury and end with an impromptu interview with State Representative Arthur O’Neill, who gives us a quick in-service on the complexity of Medicaid.

As we check facts, Lisa comments, "I think it’s also important to mention an older person’s dignity. What they put you through emotionally…here you’re already struggling with physical problems and then they put you into positions that are embarrassing, where somebody else is making decision about your fate by "following the rules". How humiliating that I need somebody to help me bathe—but I do. Getting in and out of the tub has become scary. I need somebody to help me with this, and if Medicare won’t pay for it; I have to come up with the money on my own. But where are these rules? And how does a normal person get their hands on them, so we know what we’re dealing with?"

"It’s something to think about," I comment. "Now if you need an aide for two hours a day, that’s $30 a day—more if you go through an agency. Let’s multiply that out time 365 days a year and that gives us say $11,000, which goes a long way to keeping somebody out of a nursing home that costs 270-300/day or roughly $98,000-$110,000 year (we also got a low-ball quote of $80,000). When I was working as a geriatric psychiatrist, I never once met a person, who if given a choice, would pick a nursing home over their own home. It seems like if the government is going to cough up bucks through Medicare and Medicaid, they’d be interested in saving a few dollars and perhaps garnering some good will at the same time."

"There’s nothing for the middle class," she says, "And even the program that’s supposed to help people stay in their homes—The Connecticut Home Care Program for Elders—I don’t qualify for, and that doesn’t seem fair. Arthur O’Neill gave a great quote, he said, ‘Medicaid is designed for people who are nearly destitute’. Yet, it seems to provide more of the services I need than Medicare—like home-health aides in more of an ongoing way. And doesn’t Medicaid also pay for medication?"

"It does. Now Mr. O’Neill did mention that the Department of Social Services (DSS) has a web site www.dss.state.ct.us that goes into the rules, but they’re quite confusing. ["Rules" aside, it’s a very good web site with many free brochures that explain the different programs and eligibility requirements.] He also mentioned how it’s a good idea for families to consult with an attorney that specializes in elder law, as the rules keep changing—especially as they pertain to reducing assets to get on Medicaid. It’s not like you can just give everything away to your kids, but that’s there’s actually a "look-back" period, where if people try to give away more than the allowable amount of assets during this time frame, it could land the recipients in hot water."

"Why does this have to be so confusing?" she asks.

"No clue, and it’s going to get more complex when the new Medicare rules—the "Medicare Modernization Act"--go into effect January 1 of 2006. Because when these roll out, with the new prescription drug plan, there’s going to be several different ways people can access it—some through private insurance and some through traditional Medicare. But to make it even more complex, Medicare—for the first time—will also be somewhat based on a person’s ability to pay. So, if someone has an income above 150% of the federal poverty level they’ll be able to purchase a prescription drug plan for about $35 a month with a $250 deductible."

"That doesn’t sound too bad," she says, it’s probably what I pay now through ConnPace.

"It’s not so simple, after the deductible the plan will pay 75% of your drug costs to a limit of $2250. Then it pays nothing until you reach $5100, at which point it kicks back in and you only pay 5% from then on. All in all, if you reach that point, you’ve shelled out well over $3000."

"How are people supposed to understand this?"

"There’s more too, like for those folks who receive both Medicare and Medicaid, when the drug-plans roll out, it’s not entirely clear—at least to me--who’s going to pay for what? And how?"

"All of which," she says, putting down her notebook where she’s scribbled notes from our conversation with Mr. O’Neill, "brings me back to my starting question of, what am I going to do, if they keep trying to take away my services?"

"Try to fight back. Get that attorney from Medicare Advocacy and maybe even get on the phone with the folks at Medicare."

"I hate that," she says. "They put me on hold for hours, and then when I finally get someone they tell me I’ve gotten the wrong department."

"Maybe we could document that," I offer. "Just the way they tape their phone conversations, we could do a blow-by-blow with Medicare. At the very least we could get a column out of it. Maybe try to talk to their Medical Director."

"Can we do that?" she asks.

"I don’t know, but it might be worth a try."


Services Mentioned in this column include:

The Department of Social Services-- www.dss.state.ct.us web site. Check the phone book for regional offices. They have many good brochures including one entitled "A Guide to Services for Senior Citizens in Connecticut"

The Connecticut Home Care Program for Elders---1-800-445-5394

ConnPACE 1-800-423-5026

The Center for Medicare Advocacy—1-800-262-4414