Learn the good m the bad and the ugly of Medicare and Medicaid will and will not cover and how it may negatively impact your pocket book.
Tracey Lawrence – Medicare coverage
Diane Carbo: Hi, this is Diane Carbo with caregiver relief and I have with me today, Tracy Lawrence. She is a caregiver coach, a dementia care specialist, and she’s the owner of www.traceylawrence.com she has a Facebook page called The Good Kids Club. Explain that and then we’re gonna move on to the topic of the week.
Tracey Lawrence: Okay. So it’s to my attention several years ago that a lot of people who are adult children who care for aging parents very often don’t think of themselves as caregivers. In the beginning, especially when it starts with favors and it’s this gradual adding on of responsibilities over time, these adult children, themselves as being good kids because, we’re just doing the right thing. We’re helping our parents out . So I thought, for those people who are in that position where they’re thinking this turning out to be a little bit more than I thought. I created the good kids club for people who help aging loved ones. It’s a private group on Facebook, so that people who are in that situation can share things that are going on and learn from experts in the field. I have people who are posting, different, helpful articles
Diane Carbo: you had a very interesting post by one of your good kids this week and that’s determined what we’re going to talk about today and I think that this is something every caregiver needs to know. So I’m real excited about it. Tell us about that.
Tracey Lawrence: Okay. In order to respect the privacy of the person who posted reveal that person’s name, but one of the, she was talking in great detail about insurance denial of coverage. And the kinds of things that happen to our loved ones when they have a medical situation that’s especially one that’s a little tricky and not easily diagnosed . She was describing the situation and, the way it was treated and the way it was charted for her insurance. Apparently she had a a systemic problem that was identified as a dental problem. And because it was it was shown as a dental issue. The insurance company determined that they were not going to cover.
Tracey Lawrence: She was furious. I’m grateful that she posted this, because it reminded me, this is a topic that we really need to make more people aware of. Because it’s so important to number one have the right kind of coverage. And in the case of people over 65, that coverage is Medicare. But it’s not just one thing, right? Medicare is a lot of different people programs under under that umbrella of insurance. And what a lot of people don’t know is that they can contact a Medicare broker. Who can review their benefits and review their situation. So before they choose a particular type of Medicare, they can choose something that makes the most sense for them.
Diane Carbo: Here’s the issue that I’m having is there’s such a push for Medicare advantage and we’ll discuss that but people need to be aware of Medicare advantage because it isn’t all that it’s cracked up to be. So continue on.
Tracey Lawrence: It can be great for some people. For my mom during the early part of her illness, it was actually well, but over time, you need to be willing to switch up. And folks, if you’re 64, listen up because if a decision that you make your first year can impact what you can choose later on. So before you choose medical care for yourself. Talk to someone knowledgeable. Talk to the broker and if anybody wants a referral, I know some great people. And I’m happy to share. And by the way, my website is www.traceyslawrence.com. You can just look for dementiasucks.com and that hooks you up to all my stuff too. So it’s really important to elect the right kind of insurance for your needs. And you want to build in room for changes over time. You don’t want to lock yourself into something that won’t let you change to something that’s more appropriate as time goes on.
Tracey Lawrence: Because as we age, we have more needs. And we have different needs. So by talking to a broker, it doesn’t cost you anything. Brokers don’t charge. So if you go to a broker and they want to charge you money, then run. And if you talk to a broker and they will help to point you towards the right insurance. I believe that everyone should talk to a broker every year before you sign up for your new plan, because the rules change every. year.
Diane Carbo: Not only did the rules change, but you’re changing as well. Your needs, your medications, everything. And if there’s anything I can tell you about Medicare is it’s convoluted. It’s not easy to understand and because it’s government run, it’s really screwed up.
Tracey Lawrence: Agree, so that’s why when you find a broker who you can work with, it’s their job to decipher what’s going on. They know all the ins and outs of working with it with a qualified broker, people are afraid and understandably so .There are so many unscrupulous people out there .So you always want to connect with somebody who is certified, trained, who’s licensed, who knows what they’re doing. Once you find the right person, visit with them, talk to them every year, before you sign up for your annual benefits. They will help to guide you in the right direction for what you need, where you’re at the time.
Tracey Lawrence: The other part of it is you need to have a doctor who understands how to navigate Medicare. Because what they put on your chart ,will have a great impact in what Medicare will pay.
Diane Carbo: Exactly.
Tracey Lawrence: So it’s extremely important. A lot of people when you’re middle-aged and you’re seeing a GP, okay and you may be seeing the same person for years. And you’ll keep going. But here’s the problem. As we age our reaction to different medications and illnesses changes as we get older. So it’s important to switch and start seeing someone who understands illnesses in older people. So if you can find a gerontologist. You want to make sure that you are working with doctors who know you and who know how to navigate Medicare.
Diane Carbo: You know what, and that’s getting harder and harder to find. Because doctors don’t want to take Medicare .Because the reimbursement is so low. In fact, what Medicare is doing is destroying our healthcare system. Because hospitals are closing. We now have a shortage of dermatologists and neurologists. We’re going to have a shortage of many other doctors because the teaching hospitals aren’t available in the abundance they once were because they closed. We are seeing doctors going to concierge services because they cannot continue to practice under Medicare guidelines. So that’s a whole other ball game that we can talk about another time. But when you’re talking about going to a Medicare broker, I want to tell people, I sold Medicare products. I did it because I worked for a company that actually provided a special plan specifically for patients in nursing homes. And it was the most amazing plan. But when I was selling to the nursing home patients, because it helped them stay in the nursing home instead of going up to the hospital. They provided a nurse practitioner. It was just awesome. Anyway, long story short people have to be aware that Medicare has many different supplemental plans. Every plan is uniform. Part G covers all the same things throughout every company, but the prices are different. Don’t just agree to go to a AARP they’re top dollar. So you’ll pay three and $400 for a supplement there. That you can get the very same supplement for maybe the blues for half that or less. So people need to be aware that when they’re looking for there’s supplements that they need to look at.
Diane Carbo: Do cost comparisons, be conscientious and educate yourself. Because the plans have to be uniform by federal guidelines. So that’s something that people need to understand as well.
Tracey Lawrence: So when you’re working with a broker who knows the exactly and their company is not agnostic. They don’t, they’re not working for a particular and you’re going to get the most.
Diane Carbo: You’re going to get the biggest bang for your buck.
Tracey Lawrence: Yeah and so just so you know, like how these people get paid is through commissions, right?
Diane Carbo: Yes. . Absolutely.
Tracey Lawrence: And I will tell you and I’m not surprised that you were a broker because in my experience, it’s Medicare brokers that I know are the nicest people because I get a great deal of satisfaction in getting their clients the right deal. They’re in it to make sure people are covered and that they have appropriate coverage. I’m a big fan.
Diane Carbo: And you know what people do not understand what Medicare covers, what Medicare advantage covers. They think Medicare covers everything when you get old and sick. That is absolutely not so,. That’s a shock to most people. The other thing is, they think that when they get home care that it’s going to last forever. It’s going to be covered by Medicare
Tracey Lawrence: and that’s a big one, a lot of people think that Medicare covers long-term care and it does not
Diane Carbo: no, it does not. In fact it has dramatically changed because of the aging baby boomers. We’re seeing, I think it’s 20,000 new people turning 65 since 2019. We were going to be burdened in this country. Because our generation didn’t have, have the pensions. We’re also living longer. So we have issues with trying to remain in our homes as we age. 75% of us are going to end up needing a nursing home. At some point in our lives.. the new rules, it used to be, you got a hundred days rehab in a skilled facility to improve yourself.
Diane Carbo: That is no longer the case. In fact, Medicare now reimburses at a different rate don’t want to spend that kind of money anymore on a hundred days. So they have changed it so that the facilities get a higher level of reimbursement if they don’t provide those services. In my early days of nursing Medicare would pay. You had to do it seven days a week. You had to do it twice a day in order to get paid and you had to show progress. Now, I think the therapies are not doing weekends. They’re lucky if somebody gets once a day. It may be a PTA not a physical therapist or an OT aid. Which is an occupational therapist aid. Instead of the occupational therapist. They may get it once a day or they may get it only a couple .Of times a week, which breaks my heart because people need to be encouraged. I know I was the nurse that transferred the big guys that had the strokes, the head injuries, the quads into their wheelchairs from bed, gave them their showers and stuff. My body’s ruined from that. . I know what it takes to get a person back up and running taking time to feed them and stuff. And there’s all kinds of shortcuts now and it makes me sad. In fact, I recently had a friend in the nursing home. A young guy, young as him. He’s 65. Had a major injury. And they didn’t even get him out of bed on the weekend. That made me ballistic. I’m sorry. That’s so unacceptable. To anybody because any progress they make, they lose. But when you told me about how Medicare and people are stuck with bills, I want people to know there is a a problem with going to a skilled nursing facility. You have to be in a hospital for three overnight, stays.
Tracey Lawrence: Yeah. You gotta watch out for that term observation.
Diane Carbo: Yes, because hospitals are getting penalized by Medicare. If they have a patient that goes home and then returned within 30 day period of time. What’s frustrating about this is Medicare gives them one big sum of money. So the sooner they get somebody out. The more money they have left over. A big one big pot of money for that diagnosis. So they were sending people out. I couldn’t believe what was in skilled nursing facilities. It absolutely. was frightening what they were expecting untrained nurses in these nursing homes to take care of.. It was so bad. But then they would be set right back again. Medicare would get another new pot. They started doing research. Within that 30 day period, What was happening so hospitals as the way to survive and to continue to make money .Would keep patients under observation in the same kind of room with the same kind of treatment, the same everything. But they did it as an outpatient observation. Meaning that if the person who was very ill , stayed three nights under observation, they were no longer qualified to get skilled nursing.
Diane Carbo: So people were being forced either to private, pay for care in a nursing home ,to recover and rehabilitate at a private pay at their expense or they were sent home and the family was left to try to take care of this. Which is a whole nother ball game of people uneducated, unprepared, and thrown into having to be healthcare workers. At a time when they’re just not ready. That’s still goes on. So people need to know about that and be aware there’s another situation that has occurred that I have just learned about after I was talking to you, I said, oh my God, I wonder how this is happening. What’s going on with people.
Diane Carbo: So I looked up colonoscopies are an outpatient. But people were getting these huge bills because if they had a polyp removed. I can’t tell you, you’re probably 99.9% sure that this is going to be a polyp in your colon somewhere that they’re going to remove. Then they wouldn’t reimburse because the polyp was removed. It was so frustrating for people. So there was that issue as well. So people really have to be aware of what’s covered. One of the things I find that occurs especially with Medicare advantage. This is something that people have to be aware of with Medicare advantage. The hospital you go to maybe they be paid for, but it’s the doctor that is doing the procedure? Is the anesthesiologist? Is the lab covered under that plan? If it’s not, you’re going to get a bill. .
Tracey Lawrence: Yup and you have to check every single provider
Diane Carbo: You know what you don’t know ahead of time. The hospital may not tell you. I have literally made phone calls, documented phone calls to these providers prior to a procedure. Only to find out later that they hadn’t had their contract with the insurance company renewed. So therefore it wasn’t paid . And they will come after you. That’s why I tell people, you have to be so careful at least with Medicare advantage, what happens in the beginning? Nothing makes me crazier than to see Joe Namath, to say, get what you’re entitled to. Excuse me. But. I’m entitled to quality of care at the end of my life or when I get seriously ill. When people say they’re getting free, transportation to the doctors and they’re getting dental and they’re getting. Eye,well, I’ll tell you what, it’s the same amount of dollars coming from your Medicare pocket. Medicare advantage programs are trying to cut costs. If you do your research, you’re going to learn that they severely limit you as far as your specialists, your doctors, the facilities you could go to when you need care, especially the high dollar care.
Tracey Lawrence: Yeah. That’s why I personally think that our entire medical system has to be torn apart and put back together. Because the entire premise, and this has been going on since the seventies is that we give our money to the insurance companies who then decide how that money is going to be spent. And their interest is not in our health. They’re interested in our premiums.
Diane Carbo: Their interest is in payingtheir CEOs and upper staff , big bucks.
Tracey Lawrence: And that comes from our premiums. They want money in coming. They want to minimize what goes out. So the insurance industry is not going to look fondly upon what I’m about to say. But personally, I think that what we need to do is go back to a time when we only paid for medical insurance for catastrophic coverage. In other words, when you’re hospitalized and you need a truckload of different treatments and you need to be in a building where you’re cared for by a lot of different people, then that’s when you should be insured, but for your everyday, for your exams, your procedures, for your upkeep for your, for your WellCare stuff, right? Or, if you have a cold or you have an illness where you need to go into the doctor’s office and be treated, I would much rather pay the money directly to the provider than pay to an insurance company who’s going to make a decision, which is completely based on money whether or not, they’re going to pay for the care.
Diane Carbo: That’s the plan that the national association of self-employed used to sell. There was a plan just like that where you got to choose, and it makes so much difference. I will tell you that’s why doctors are going to the concierge services for that reason alone as well.
Tracey Lawrence: Yep. And I think that’s the way to go. I would go directly to my provider and how much money they would save. Just I’ve been to doctor’s offices where they hire so much staff just to be able to get through the claim.
Diane Carbo: What’s funny about that is doctor’s offices have more people doing less for the patient and more on the paperwork than ever before. In fact, doctors offices are closing because they can’t afford to even make the income to pay their school loans off anymore. That’s a very serious issue.
Tracey Lawrence: I’m just saying if we eliminated the middlemen, who are these insurance companies who are making arbitrary decisions for us based on what makes the most money for them? If we were able to just stop paying for insurance and pay for the doctor services as needed, we would all come out ahead.
Diane Carbo: I agree. And you know what I say same way with our Medicare part D. I will tell you that nothing makes me crazier than to see I’m paying a monthly premium because I’m forced to under Medicare part D to pay for coverage for my medication. The problem with this system is that. You have to know what medications you’re on and someone like me who is in transition and I’m 68. I have chronic pain. I’m struggling with many things right now. Here’s a perfect example of you hit your donut hole, which means in September or October, you’ve already maxed out. Which we shouldn’t do max out my benefits. So I have to private pay for a lot of medications. And this has been going on for decades with seniors. Our politicians continue to taken care of by big pharma for financial gain for themselves than to take care of us. Here’s a perfect example of something that happened. I know that many don’t let Trump. Okay. I get that, but he was literally such a threat to big pharma. He signed an executive order decreasing the cost of insulin and epi pens too affordable. They have gone up over 500% in the last 10 years in pricing, and these are expensive medications that shouldn’t be when the rest of the world is not pay in those prices. And the first thing, Biden absolutely eliminate. Negatively impacting millions of people that depend on those drugs. And epi pen alone is like $600. And that’s a life saving medication that people need if they’re stung by a bee or have, a nut in their food that they didn’t know about. I am a firm believer we should privatized Medicare. I know people will think that’s terrible. That’s just my opinion. But the other thing we need to do is if Medicare Medicaid, the medical delivery system, healthcare system for the military and the VA would purchase in one lump sum all these medications and get rid of the big middleman, we would be able to have much more cost effective . , but they don’t want to do that because we have pharmacy benefit managers and then we have that sell the drugs to the pharmacies. So every tier of that we have adds on more and more so that everybody gets their piece of the pie.
Tracey Lawrence: Absolutely and that’s the thing was insulin it’s absolutely horrifying. Under Trump the insulin was down to an average monthly supply was like 30 bucks a month and now it’s 600 and I cannot fathom why it was a good idea. To eliminate the executive order that the previous administration issued to help people who are dependent on these drugs for their very lives.
Diane Carbo: People have to understand elections have consequences and one of the things is big pharma was so threatened by their income and Trump that they spent tens of millions of dollars to get Biden elected. They really did and whether you’re a Democrat or Republican or an independent, it’s sad when government feels that they need to be beholden to an organization and they don’t look at what’s best for the American citizens, but what’s best for their own pocket.
Tracey Lawrence: That’s right and what we are all failing to recognize right now is that they’re supposed to be working for us.
Diane Carbo: When people are considering free Medicare for all, just look at what’s going on in Europe and pay attention because what’s happening is, and I learned this decades ago. I used to have Canadians come down to Minneapolis and to Rochester at the Mayo clinic for timely treatment. What happens with universal healthcare is gonna be the same thing as that’s happening here. Now, the wealthy will always be able to private pay for their care in a timely fashion, they call it, jump in the queue and when they need treatments, if they’re private pay, they’ll get the treatment. So middle-class will still have to take their assets and sell them. And make financial decisions in regards to if they want timely treatment and get it or not. The poor and the lower middle class will continue to wait and wait. Perfect example is I can’t tell you how many people I know that have been delayed weeks .They are actually on an on-call list for surgeries for heart, for hips, for whatever. And you can be delayed as long as a year or longer for a procedure because people jump the queue. Because they either have a private insurance that is allowed in their country or their private paying for the procedure.
Diane Carbo: Yes. So when you think you’re going to get the best possible care, it’s not going to be timely and people are going to die and get ill.
Tracey Lawrence: Absolutely. We have the power with our voices and with our votes and with our involvement to change this. But we have to get the right people on our side, running for office and representing our interests the way the founders intended for our country to run.
Diane Carbo: Exactly.
Tracey Lawrence: It’s not running for the people.
Diane Carbo: It’s corporate interests and personal financial gain for the politicians . So on that note, Tracey, I’m so glad that you brought this subject up because I’ve been wanting to discuss this for a long time I tell my caregivers, remember caregivers, you are the most important part of a caregiving equation. Without you, it all falls apart. So practice self-care every day. Learn to be gentle with yourself because you were worth it. And Tracey, until next week, I look forward to speaking with you again and we’ll have another great topic.
Tracey Lawrence: Okay. We’ll work on. I’ll be watching for input from a good kid.
Diane Carbo: There you go. Okay. Have a good day. Bye bye now.