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The Senior Hub Podcast is a resource hub for planning and caring well for your aging parents and loved ones. This podcast tackles everything from data, to key terms, to personal stories, to sacred moments, to tricky family dynamics.
Join hosts Daniel Alexander and Rebecca Hill as they engage their guests, and each other, on this most important topic. We are all learning about this topic as we get older. Let's do it together.
Find us at www.theseniorhub.com
Well, hello, and welcome to the Senior Hub podcast. I'm Daniel Alexander, the founding director of Senior Hub, and I'll be your host for today's conversation. Our hope is that each time we do this, by the time we're done, you'll feel a little more equipped and maybe even a little more hopeful for whatever's ahead. So without further ado, let's dive in. Today, we have with us, as we have in this whole series, Rebecca Hill, our chief care strategist.
Speaker 2:Hello again.
Speaker 1:Hello. We are currently in a series of conversations following the story of a woman named Margaret. Margaret is 78. She's from Raleigh. She lives in Raleigh.
Speaker 1:She's widowed, has three kids, and one of those children is nearby in in town, and two are out of state. She recently fell and broke her hip. She had surgery and then made her way through the hospital to rehab and has been working hard in therapy. And now today's episode, the paperwork has arrived. The hospital bill and the rehab statements, numbers that nobody was really fully prepared for as far as how many numbers are on the page, but also how to translate them.
Speaker 1:Most families do assume that Medicare covers most of it, and it does cover a lot, but there is a structure to how this works at a point where it starts and ends and people don't understand until they're right smack in the middle of it. So today, we're going to pull back the curtain a little bit on the Medicare maze, as we call it, and Rebecca's going to help us start understanding the bills and what to do next. So, Rebecca, let's start with that, the Medicare maze. That's the term we've heard about. Why don't you just talk us to us about what that term and why this is so complicated?
Speaker 2:Yeah, yeah. So aptly termed the Medicare maze. So we are going to give basic high level overview about what is Medicare? What are its parts? What portion of this episode are we going to apply to Medicare a, b, c, and d?
Speaker 2:There are other letters involved in the Medicare structure, but for our purposes here, we're gonna talk about the hospital stay in terms of Medicare Part A. We'll get into B later. You should know that C is termed a Medicare Advantage plan and D is essentially for prescription drugs.
Speaker 1:Okay, so you sent us in the deep end pretty quickly here. So you're telling me there's a lot of parts to Medicare. Portions. A, B, okay, they're called portions. A, B, C, D, does that go all the way through Z?
Speaker 2:To be honest, I'm not sure. But there are other letters, there's a part N.
Speaker 1:All right, and if you've been paying attention to the political arena, as they've tried to redo Medicare, there are thousands of pages about what Medicare is and how to revamp it and all the different pieces. So this is incredibly complex subject we're diving into today.
Speaker 2:That's right.
Speaker 1:And what I'm hearing from you is let's just focus on Medicare Part A.
Speaker 2:Because we are focusing on Margaret and her episode, She's fallen. She's broken a hip. This is a very common scenario, and we just want to parse out how is this getting paid for? And we begin with our foundational, insurance coverage, which for people who are 65 or older is Medicare Part A and B.
Speaker 1:Okay, so Medicare Part A and B. Can you give me a little bit more before we talk about the hospital and rehab and how that all works about the other pieces first? So let's do a sidebar on, I've heard the terms Medicare Advantage or Medigap supplemental things. What are the other pieces that are going to go alongside this Medicare A and B we're going to talk about?
Speaker 2:Doctor. Yeah. So think of Medicare Part C your advantage plan.
Speaker 1:Okay.
Speaker 2:It may cover some of your drug portion. People choose Medicare Advantage based on their specific needs in terms of diagnosis and how many medicines are they taking.
Speaker 1:Okay.
Speaker 2:Here's where I would defer to somebody who is, a Medicare Advantage advisor an And then, as I said before, Medicare Part D is that prescription drug coverage. Everything beyond that is what we're calling Medigap or supplemental insurances.
Speaker 1:Okay. So give me a little bit more about supplemental insurances. Are these normal insurance companies like Blue Cross Blue Shield or how does that work? What are supplemental?
Speaker 2:So supplements are provided through independent private insurance companies. So you mentioned Blue Cross Blue Shield is, locally here, widely used. Humana, there are even like parsed out programs, Anthem and United and other groups who provide.
Speaker 1:Okay. So those are just like pre sixty five years old insurance that we all carry or would have through our companies.
Speaker 2:Well, way you purchase it is the same. So you're looking to a private provider to sell you supplemental insurance.
Speaker 1:Okay. Yeah. And when do you purchase supplemental insurance? How does that work alongside of purchasing or having
Speaker 2:So during open enrollment periods, you can opt to change up your supplemental insurance or even the type of Medicare that you're receiving. So if you're not an Advantage Plan member during an open enrollment, you can become an Advantage Plan member, if that makes sense for you.
Speaker 1:Okay, okay, that's great. So what is the takeaway for the family on how to figure out what's going on?
Speaker 2:Yeah, so the first takeaway here is just understand what's already in place. For Margaret's family, she just really needs, they just need to pull the cards.
Speaker 1:Okay, the literal cards.
Speaker 2:Yes, look to her wallet. Where is her Medicare card? Where are her supplement insurance cards? Each of these supplements does provide a card and on it, it will tell you what part of Medicare it's applied to and, who is the provider. Doctor.
Speaker 1:Great. And again, this is probably one of those things that a family can do now, way before a fall or a hospital stay, like An actual visual card, just having a copy of that, knowing where that is is awesome.
Speaker 2:Take a photo. Put it in your Google Drive or however you're storing Margaret's information. You can just have that awareness.
Speaker 1:Okay, perfect. So step number one, find the cards, figure out what's on them, and you know what's going on. All right, so let's go back to Margaret as she goes to the hospital, and we're thinking about Medicare and these supplemental insurances. Talk to us about what we should know or do as a filling representative to make sure that insurance is going to cover what it needs to cover.
Speaker 2:Sure. So there's several pieces here, but the first is understanding how Margaret's hospital stay is being qualified.
Speaker 1:Okay.
Speaker 2:Is she admitted to the hospital? Observation status or admitted status?
Speaker 1:Okay. So, which comes first? Like talk to me about those terms.
Speaker 2:Yeah. So, if you recall back in the first episode, we talked about at the ER, Margaret was held in an observation status.
Speaker 1:Okay.
Speaker 2:The key takeaway here is that Medicare is not starting an episode or a benefit period, without an admitted status. So it's really important for Margaret's family to understand, is Margaret actually admitted into the hospital and how long has she been admitted? Because there is something within the industry understood as the three day rule, which means that Margaret needs a qualifying hospital stay of at least three days for Medicare to then pay for any continuing healing in a skilled nursing facility.
Speaker 1:Okay, okay. So we are gonna, let's come back to that because we're gonna, when Margaret leaves, I need to make sure I'm clear about how that plays, but I wanna make sure we land the plane on observation versus admitted. Sure. So when Margaret first goes in, the doctors are observing her.
Speaker 2:That's right.
Speaker 1:So that makes sense that that would be called the observation period. And we'd certainly want the doctors to get this right as to what's going on. So we are okay with observation for a little while.
Speaker 2:A necessary period.
Speaker 1:But what I want to do as an advocate or a family member is to push for her to be admitted. Absolutely. Because that's when Medicare will start and start moving through the pipeline of her stay is when she's admitted. Is that correct?
Speaker 2:Again, an observation period is necessary. It is a determining time period where physicians and clinicians are just gathering information as the term states, observation. But to have the hospital stay covered, you really want Margaret to be seen under an admitted status. Okay. So it is important to advocate for, understand how she's being served in the hospital, and then you do really want to begin the episode as soon as possible.
Speaker 1:Got it. Alright. So we want to be observing, but we also want to be moving forward as quickly as possible.
Speaker 2:That's right.
Speaker 1:Okay. Great. So she's been in the hospital. She Margaret did have surgery. She was recovering in the hospital, and now they're deciding that it's time for her to move into a skilled nursing facility for her rehab.
Speaker 1:So she will move to this facility and begin that. Does Medicare go with her naturally? You just talked about three day rule. Let's recap that again.
Speaker 2:So the three day rule is she's had a qualifying three day hospital stay that now has begun her episode and Medicare Part A will cover all her healing from day three forward.
Speaker 1:Okay.
Speaker 2:So you could have been in the hospital for five days. You were under observation status for two of those days. The the admitted status is what begins the episode or benefit period. So episode equals benefit period. Mhmm.
Speaker 2:You wanna begin that as soon as possible so that you meet that three day qualification period and Medicare continues the coverage day one through 20.
Speaker 1:Alright. So what should we do if the doctors would like to release Margaret after two days of being admitted? It depends.
Speaker 2:It does depend, which is why I'm but the three day rule is qualifying hospital stay to get the skilled nursing facility coverage paid for.
Speaker 1:Okay. So you're not making medical advice here. I'll give you that. So let me rephrase the question or maybe summarize what I hear you saying is if she's going to be released to a skilled nursing facility after two days, maybe have the conversation about having her stay in the hospital for until the third day, because that's when Medicare will carry on to the skilled nursing facility.
Speaker 2:That's exactly it.
Speaker 1:Okay, great. So let's take her into the skilled nursing facility. Medicare is continuing with her, Part A, that is. I just heard you say things about till twenty days and then one hundred days. Can you talk us through how long can she stay in that facility and have Medicare cover her?
Speaker 2:So there's another industry term called the one hundred day cliff. So days one through 20 are Medicare A covered at 100%. Day 20 to 100, you may have a copay unless you have the supplemental Medigap insurance that we talked about earlier that is designed to fill in the gaps around Medicare Part A and the things that it does not cover.
Speaker 1:Okay. What happens at day 101?
Speaker 2:Well, at day 100, Medicare stops paying for any stay in the skilled nursing facility, the patient is then responsible for those bills, the stay itself, any therapies received, any medicines received.
Speaker 1:Okay. And would they possibly have other insurance that would help with that? Or is that always everybody's bets are off after one hundred days?
Speaker 2:You are paying out of pocket after one hundred days.
Speaker 1:Okay, all right, so that's very important. We have a three day rule, and now we have a one hundred day cliff.
Speaker 2:That's right.
Speaker 1:Those are the two industry pieces we want to keep our eye on. Okay, so say she's coming home after twenty days or so, and there's all these other things that are going on. Talk to me, let's do one more term here, long term care insurance.
Speaker 2:Yeah.
Speaker 1:How does that play into this conversation?
Speaker 2:Doctor. So long term care insurance does pick up after you can employ it. So it's a choice that you make to employ your long term care insurance benefit, to receive some of the extra skilled nursing stay. I think we might want to pivot and hold on to this conversation for later.
Speaker 1:Okay.
Speaker 2:But I think it's really important to just identify there is a Medicare one hundred day cliff.
Speaker 1:Got it.
Speaker 2:And we should be timing out Margaret's hospital stay according to those rules. Day one through 20 is fully Medicare A covered 100%, and then you need to know, does Margaret have Medigap insurance if there's any copay required for days 20 through 100.
Speaker 1:Okay. So she was observed in the hospital, and then she was admitted for at least three days. She moves to a skilled nursing facility. Medicare A is on top of that whole time period up through or up until one hundred days. Yeah.
Speaker 1:And again, if she fell, give us an estimate. If someone falls, breaks a hip, has hip surgery, are they in rehab for one hundred days normally, or how long do Not they normally. Stay?
Speaker 2:You know, a couple of weeks on average just to stabilize, return to walking, ambulation status. One hundred days is rare.
Speaker 1:Okay. So in this scenario, we're not as worried about that one hundred day cliff, but that can be, if there's other complications or other injuries or other pieces, that's certainly an option. Sure. Yeah. Okay.
Speaker 1:All right. Well, then can we go back to long term care? Because I am curious about that. I've heard about it, but is that a normal thing people carry these days? Where does this term come from?
Speaker 1:And should we be thinking about it?
Speaker 2:So think of long term care insurance as supplemental that you choose to buy into. A lot of people, were offered it as a benefit as part of their employment package, just as you would opt into a four zero one ks, you would opt into a long term care insurance benefit. Each is structured differently, but I think it's important to know that you've been paying over several years, a monthly premium for the long term care insurance. And if, you find that you are now needing care that support where you need support for at least two or more activities for daily living, it might be time to employ your long term care insurance benefit.
Speaker 1:Okay, so let me ask a question that you may not want to answer. Should everyone have long term care insurance? Or do you want to defer that question?
Speaker 2:I think it's a great supplement to have. This is a question for your wealth advisor, your financial planner, they know how your assets are structured, and they can guide you more specifically about what makes sense. If you're a couple, if you're a solo ager, all of those factors play into whether long term care insurance makes sense for you.
Speaker 1:Perfect. Okay, so let's make sure we have the other professionals in the room as we're having these discussions.
Speaker 2:So true, the hub.
Speaker 1:Yes, we will point you that way. All right, so let's round out the conversation with other family advice that you would have during this time period. What would you tell families, maybe these are summary statements you want to make for us, about costs, insurance, the hospital, and rehab in particular?
Speaker 2:Yeah, I think the main takeaway here is have the information readily available so that you can make an informed decision. Half of the tension in these conversations come from people arguing about what's on the table and what's not. I think just having that baseline understanding, education and knowledge about what Margaret has available to her specifically, then can create informed decisions later.
Speaker 1:Okay, great. And then to recap what I've heard so far, it's important to get admitted in the hospital to stay three days. And I've heard you say in the past to ask questions in the skilled nursing Is it okay as a family member to ask the doctors questions about why and how this connects with insurance or, you know, how to get a more full story about what's going on?
Speaker 2:Doctors will speak to you about diagnoses and outcomes. They're not necessarily gonna advise you about how to get it paid for through Medicare. I think you should ask questions of the doctors related to how is this treatment plan, specifically going to play out for Margaret, and then utilize the hospital staff, the case management staff, the financial, people within the hospital and say, you know, according to Margaret's status now, how is this gonna be billed to Medicare Part A? That is always a great question and have understanding about how they're coding her stay so that you know which pieces will be picked up, which pieces might require a coinsurance or a Medigap, and asking questions so that you arrive at as much understanding as you can possibly gain is Okay, the
Speaker 1:great. So certainly people can call you for questions. What is your other advice for who they should call for help in understanding their Medicare insurance and these other pieces?
Speaker 2:People can certainly call their financial planners. They can take advantage again of the of the hospital financial staff, the billing departments there. They'll have real time updates Margaret's being billed for.
Speaker 1:Okay.
Speaker 2:And it's okay to ask those questions even while Margaret's still in the hospital.
Speaker 1:And certainly, would assume you can call the number on the back of your insurance card and You talk to your insurance
Speaker 2:may have long wait times. Be prepared to be in a queue, but certainly ask all the questions even while she's still within the hospital stay.
Speaker 1:Perfect. All right, so the next step will be leaving rehab, then And she'll go there's all kinds of other questions that we have and other costs, I assume, about what do we need to do in her own home to make it safe? Or can she stay there? If she can't stay there, all the costs associated with other living situations and all the other pieces that she'll need. I am going to offer that we pause here and save that for the next episode of The Senior Hub.
Speaker 1:Does that work Sounds for
Speaker 2:great.
Speaker 1:All right. So thank you all for joining us today. That's our conversation. Thanks, Rebecca Rebecca, for sharing your wisdom with us. Our hope is that you are all walking away a little more equipped and maybe a little more hopeful than when we started.
Speaker 1:Wherever you are on this journey, call us at any point. We are here to help, and thanks for joining us. We will see you next time on the Senior Hub podcast.