Even
with expanded benefits, you may be on the hook
by Phil Moeller |April 17, 2019
Don't
count on help from Medicare to build this ramp
As you or your
parents get older, healthcare costs can include far more than prescription
drugs and doctor co-pays: As you age and become less mobile, you may also have
to spend money on upgrades to stay
safe at home.
In this week’s
column, Phil Moeller, the author of Get What’s Yours for Medicare: Maximize Your Coverage, Minimize Your
Costs and co-author of the updated edition of How to Get What’s Yours: The Revised
Secrets to Maxing Out Your Social Security, answers two reader
questions about what home improvements Medicare will cover.
Got a question of
your own about Medicare
or Social Security?
Send it to askphil@considerable.com.
Will Medicare
Advantage cover a ramp for my mother?
Karen: I just read about Medicare changes
for 2019 and a widening view of home safety adaptations. I am
writing you to request guidance in ending my relentless Google searches on this
topic!
Our scenario: My
mother is a relatively healthy 77-year-old who lives on 14 acres with two dogs,
three horses, and an atypical Parkinsonism tau protein disorder diagnosis
(PSP/CBD). This is a neurodegenerative movement disorder that results in
balance issues and lots of falls.
She wants to remain
as independent as possible at home. Her entryway is a deck with eight steps
leading to it. A few months ago, she fell backward down these steps. So now we
need a ramp, which would be about $2,500 to build.
We are fortunate and
ready to self-pay it. But I have read a number of references from you and
others regarding a new group of benefits to help people safely age in place, as
well as a more generous view of home safety adaptations.
Her primary care
doctor approached her Medicare Advantage insurer to ask about coverage for such
an entry ramp. The insurer’s response was, “Medicare doesn’t pay for that, so
we won’t cover it.” This seems contrary to what I have read; yet I am unable
to locate anything from the Centers for Medicare & Medicaid Services (CMS)
or on the Medicare.gov
website that addresses the matter.
I feel responsible
for using my mother’s resources wisely and a bit of a commitment to have this
corrected if her insurer has simply not communicated 2019 changes to its
organization and staff effectively.
Would you direct me
to a documentation to effectively support my argument or correct me if I am
wrong?
Phil Moeller: Gold stars for
wanting to help your mom, and for doing your homework.
These non-medical
benefits (that’s my shorthand, not Medicare’s language) are not fully spelled
out by Medicare, but the agency has indicated it would look favorably on
insurers who proposed them. Here’s the 2018
CMS memo that lays out the agency’s initial description of these
benefits.
These new Medicare
Advantage benefits might include equipment to keep older adults safe
at home, such as grab bars, temporary ramps, and stair rails.
Insurers do not have
to offer these benefits, and if they do, they have a lot of discretion about
what to offer.
This year is the
first year such benefits are possible. The timing of the 2018 CMS guidance memo
did not leave insurers much time to develop new benefit rules, and relatively
few insurers have included them in their 2019 Medicare
Advantage plans. UnitedHealthcare, in particular, said at the time
that it would take a conservative approach and did not make much use of these
new benefits in its 2019 plans.
The bottom line, as I
see it, is that insurers may but do not have to offer these benefits, and if
they do, they have a lot of discretion about what to offer and whether to offer
it to all policyholders in a plan or to a select few.
(The ability of
Medicare Advantage plans to pick and choose who gets benefits is a new tool
given to them by Medicare and, I suspect, will create many fairness issues down
the road.)
So, her insurer’s
response is correct. And even among insurers offering these expanded benefits,
I would be surprised to find one who would now cover a $2,500 ramp.
If her primary
physician prescribes physical therapy as being medically necessary, Medicare
will cover it.
Having said this, I
would not give up hope for the future. Earlier this month, CMS issued its formal notice
to Medicare private health plans about changes it is seeking in 2020 plans.
This notice included providing Medicare Advantage plans even more flexibility
to offer non-medical benefits next year. Even before this notice, MA plans were
expected to boost their non-medical offerings next year.
Also, while you may
need to pay for your mom’s ramp, there is a good possibility that Medicare would
cover at least some of her physical therapy. If her primary
physician prescribes such care as being medically necessary, Medicare will
cover it. And coverage of this benefit does not hinge on whether the therapy
will actually improve her health, just that it will help her.
Good luck, and please
let me know if you need any other information about Medicare coverage for your
mom.
Will Medicare cover a
special chair?
Question: I have very bad
knees. Can Medicare pay for a chair/recliner that lifts you to a standing
position so I then can walk?
Phil Moeller: I’m sorry to hear
about your knees. Generally, Medicare only covers care and equipment that is
considered medically necessary by your doctors or other licensed caregivers.
If getting help to
stand up improves your health, you might be covered. However, it’s unlikely the
full cost of a lift chair would be covered. More likely, only what’s called the
“lift mechanism”—the tension-loaded device that elevates you—would be covered.
These units, with
more modest costs, would be placed atop the seat of a sturdy chair and provide
the lift benefits you need.
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