My friends talk about a Prescription Drug "Donut Hole". Can you explain what that means?

Medicare Prescription Drug, Part D covers prescription medications. Part D plans have an initial coverage period (in 20016 up to $3,310 in medication costs), which may include a deductible. Then the person would most commonly have a coverage gap or donut hole. Drug manufacturers write off a portion of the drug costs during this period so that the insured pays 45% of brand RX costs and 57% of generic costs. After the insured has paid $4,850 out of pocket, the Part D plan pays all but 5% of drug costs or a small co-pay.

Recently I started looking for a place for my mom to live. I found this process confusing. So, what should I look for when looking at senior living communities? John H., Dunlap, IL

When looking for a senior living community one cannot afford to make a poor decision. This can become a very stressful time for all family members. But where to start? Sometimes it is good to know what mistakes people make while doing this search. Selecting a senior living community can be made easier if you plan ahead as opposed to waiting until change in health or a chronic condition worsens. Assuming one is planning; the first mistake is: 1. Not researching what types of senior communities are available. In Central Illinois, there are clearly about four types of senior living communities: Endowment Homes, CCRCs, Assisted Living, Supportive Living and Independent Living. Basic differences in homes include. Endowment home- will care for individual once a resident for the rest of their journey. CCRCs- continuing care retirement community- tiered approach to the aging process and has all services necessary for future living including a skilled nursing unit. Assisted living- provides some nursing care, housekeeping, and prepared meals as needed. Supportive living- Care much like assisted living, but may be more appropriate for lower-income older persons. A person may spend all of their assets and stay here while going onto Medicaid. Independent living- facilities for the elderly that are less restrictive. There may be an arrangement with a home care company that can be hired on an individual basis on site. Residents in independent living are considered to be living in their own independent apartment.

Recently I started looking for a place for my mom to live. I found this process confusing. So, what should I look for when looking at senior living communities? John H., Dunlap, IL

When looking for a senior living community one cannot afford to make a poor decision. This can become a very stressful time for all family members. But where to start? Sometimes it is good to know what mistakes people make while doing this search. Selecting a senior living community can be made easier if you plan ahead as opposed to waiting until change in health or a chronic condition worsens. Assuming one is planning; the first mistake is: 1. Not researching what types of senior communities are available. In Central Illinois, there are clearly about four types of senior living communities: Endowment Homes, CCRCs, Assisted Living, Supportive Living and Independent Living. - Basic differences in homes include Endowment home- will care for individual once a resident for the rest of their journey. CCRCs- continuing care retirement community- tiered approach to the aging process and has all services necessary for future living including a skilled nursing unit. Assisted living- provides some nursing care, housekeeping, and prepared meals as needed. Supportive living- Care much like assisted living, but may be more appropriate for lower-income older persons. A person may spend all of their assets and stay here while going onto Medicaid. Independent living- facilities for the elderly that are less restrictive. There may be an arrangement with a home care company that can be hired on an individual basis on site. Residents in independent living are considered to be living in their own independent apartment.

Should I opt out of my Medicare Advantage Plan if I am expecting a major procedure in 2016? -Timothy J., Peoria, IL

This is a great question, and involves a bit of number crunching on your end. The first thing to note is that this will vary on a case-by-case basis, but looking at potential costs, especially between Medicare Advantage Plans (MAP, or MAPD with prescriptions) and Original Medicare with Supplemental Plans and Part-D for drugs, is something I get asked about quite a lot. Here is how to think about this to find the best solution:

First – If you are thinking of switching now, you are acting at the right time. You have until February 14, 2016 (it is always January 1^st to February 14^th each year) to opt in or out of MAPD, without special exceptions granted in certain circumstances year-round.

Second – This is truly a numbers game, if number crunching is not your cup of tea, please consult a professional, the following is for the DIY folks only!

To figure out if switching is right for you, find out approximately how much it will cost for your procedure, new medication, and each day you expect to spend in the hospital under MAPD and add all of that together (do not forget to take in to account your deductibles, out of pocket maximums, etc.). Now, divide that number by 12 and add it to your monthly premium, this number is your expected cost per month under MAPD. Now, if you find that your expected monthly costs are far higher under MAPD than Medicare with supplemental plans, then your answer is simple.

Finally – If you want to disenroll from an MA-only or a MAPD plan and return to Original Medicare during the allotted time mentioned above, you have a special election period (SEP) to join a Part D prescription plan.

• If you have a MAPD plan, you can either 1) submit a disenrollment request to your MAPD plan and then enroll in a Part D plan, or 2) the easiest way is to properly enroll in a Part D plan first, which then automatically disenrolls you from your MAPD.
• If you have an MA only plan, if just going back to Original Medicare - you must request disenrollment from your MA plan.  If also enrolling in a Part D (RX plan), you may properly enroll in a Part D plan and that will cause your dis-enrollment in the MA plan.

Of course, you should always speak to a professional before committing to any large changes such as this, but it is always a good thing to have a general grasp on your insurance coverage for the year at the start of the year.

My son is turning 26, and this year will become ineligible to remain on my employer-provided health insurance. He has a low/moderate wage job (makes about $30,000 a year) that does not offer health insurance as an option, and is considering using Healthcare.gov to get insured. Are there any pros or cons we should be aware of? -Lynn G., Peoria, IL

First off, Healthcare.gov is an extension of the Affordable Care Act (ACA), also known as Obamacare. ACA was made to be an option for those, especially in an income range up to 138% of federal poverty level (a range up to about $47,000 for a single person), to receive coverage with reduced cost. This cost comes in the form of a tax-break or subsidy to be applied directly to premiums or when filing taxes at the end of the year.

It is important to note, however, that insurance agents can still be involved in this process, and many resources can be used other than Healthcare.gov. We advise you always speak to an ACA insurance professional to find what coverage you need and help to navigate this process beyond just pricing premiums.

Also - Open enrollment ends very soon, January 31^st, 2016, meaning that unless your son, or any party interested, were to meet the specific criteria to apply out of the enrollment season - the window to apply for ACA insurance is closing fast.

As with any insurance, consider what level of coverage is needed for the individual. Many healthy 26 year-olds only seek catastrophic insurance with minor coverage for things like visits, and little worry for out of network services. This will vary radically on a case-by-case basis, so figure out what level of coverage works best for you. Of course, talking to a professional agent will likely be a huge help.

My parents are aging and still live in my childhood home. I feel that they should not stay there much longer, but am unsure when the right point to have that conversation is. What should I look for? –Bridgette R, Bloomington IL

Often times this does become a tough issue for both parties. They may feel the same way you do, but be unsure of what that could mean to the children and grandchildren. Things like ‘but where will we celebrate the Holidays?’ often prevent grandparents from downsizing their homes, shift to living with family, assisted living or other options.

Look for the signs.

• Are they using the rooms upstairs or having difficulty doing so?
• Is the yard as maintained as it used to be?
• Is there a risk of falling in the home?

Sometimes the answer is not for them to leave, but to augment the environment. Being vigilant about the signs of your parents being overburdened and assisting with altering their environment can keep them happy and healthy in their home longer.

Whatever happens, research assisted living homes now for the future. Figure out who offers what and where, and have an idea long before anyone needs a facility which you may prefer. Living By Your Design has a free senior community referral service that can help you match your needs and wishes with available communities in the area.

I will soon take start my Social Security collection, what are some tips to help offset some costs post-retirement? -Deborah G, Peoria IL

On top of your regular finances in the later years (pension, 401k, social security, etc.), it is wise of you to consider other ways to help mitigate costs in retirement. Here are some things we recommend frequently to help with just this:

•  Schedule an appointment with your insurance agent to update policies every year.  At this point in life the needs of your care will change over time, and your insurance coverage will likely need amending to accommodate that. Always make sure you have the best coverage for your needs and medication, your plan should feel yours.
•   If you or your spouse is a United States Veteran and either of you require daily assistance with medications or self-care, you may be eligible for a monthly Veteran’s pension to augment your Social Security or other pension income.
• Consider long-term care policies.  If you already have it, read the fine print. These products have changed over the years so review your coverage to make sure you understand what it does and does not cover.
• Seek out a trusted third-party specialist to help navigate these things. There is a community of professionals that want to help you.

My Medicare Annual Enrollment Period packet has arrived, it seems like a lot of information, what should I watch for? Kathleen W., Morton, IL

These plans can change yearly, so review your plan’s annual renewal information carefully.  Some people may receive a letter from their MA (Medicare Advantage) or Part D (Medicare Drug Plans) company discontinuing their plan for 2016. If this happens to you, you will need to take some action or you will be put back into original Medicare by default.  On the other hand, this letter will guarantee that you can move to any plan in the state, so do not throw it away.

Additionally, ensure that you:

·         Review your benefits, they may have changed

·         Check to make sure that your providers are still listed as in network

·         Make sure your drugs are covered, watch for any new restrictions

·         Look at your copays for the new year

·         Contact your insurance company with any questions

·         Consider consulting a  local insurance agent, they know the environment for the new year as it applies locally, typically better than someone from a national organization

·         Be an advocate for yourself, ask questions about what matters to you and take the time to get answers

·         Remember that nothing comes ‘free,’ a low-cost plan is likely that way for a reason

What is patient advocacy, really? Is this service for me? –Melanie J., Bloomington, IL

A patient advocate is a consultant who supports a client with a variety of needs, both in a medical setting and at home.  They may be a medical professional, a social worker, or a lay person with experience with chronic disease or with helping a loved one navigate their own health journey.

In a medical setting, patient advocates can accompany clients to doctor appointments or outpatient rehab sessions.  As a result, they can communicate with medical staff and family members about the patient’s ongoing condition, medical compliance and related concerns.  They can also help with the filing of insurance and medical claims.  Through home visits, they develop a relationship with the patient and monitor health progress by taking vitals, overseeing the correct use of medical supplies and equipment as well as keeping track of medication usage.  They may also make suggestions for physical changes to the home environment to ensure safety by assessing fall risk and potential hazards due to limited mobility.

Ultimately the patient advocate can serve many functions, but their primary function is to advise and assist throughout the treatment process. Patient advocates are often vital for major decisions in the change of care or environment, such as when it is too risky to have a patient living alone, or when to begin worrying about quality of life over aggressive treatment. Ultimately, it is the job of the advocate to help patients and their families navigate the healthcare system.

Is it in my best interest to utilize a private patient advocate, even when advocacy has been assigned through my insurance already? –Carlene G., Peoria, IL

While any patient advocate will help in navigating through tough medical struggles, both at home and in the hospital, it is important to note that there is often times a level of loyalty toward the wishes of whoever is ‘footing the bill,’ so to speak.

For instance, an insurance appointed advocate will likely have some level of the insurance company’s interests in mind. While it is unlikely they would ever provide bad or dangerous advice for the patient, they will likely have the reduction of cost to the insurance company in mind.

Advocates can also be appointed by the hospital itself, but they may also have their own goals in mind. Many hospitals receive a small penalty for patients being readmitted to the hospital within a certain period, and a hospital appointed advocate may have this or other things in mind when recommending a course of action.

While the difference may be slight, being the sole employer of a patient advocate does insure that their allegiances lie solely with the patient and their families. Perhaps just receiving a consultation from a private advocate to supplement your appointed advocate would suffice, but it is definitely something to keep in mind.

What are “triggers,” and are they truly necessary for payable claims in Long-Term Coverage Insurance, and how do I watch for them? Jen A., Peoria Heights, IL

'Triggers' are essentially the conditions necessary for benefits to be payable. To make LTC claims for specific diseases or disorders there are often a list of many possible triggers, with a set number necessary to make a claim based upon that condition.

For instance, if one seeks long term care in a facility based upon a struggle with dementia, usually two of 5 or 6 triggers are required for the insurance company to deem payment of the claim to cover the facilities costs necessary. These triggers are very specific, such as whether or not the person needs 24 hour care, and if not whether or not they can properly bathe or dress alone, and triggers such as eating without assistance.  Assistance could mean standby or substantial assistance.  Standby assistance is much easier to meet.

The reason this question comes up so often is that these triggers, and the failure to prove them to insurance companies, can often lead to a lack of payment for coverage that has been purchased and is, in fact, owed. The difference between understanding the triggers in insurance plans purchased, or to be purchased, can be the difference between many thousands of dollars in payable claims each month.

My advice: seek professional help both when purchasing your LTC plans and when it comes time to make a claim.

When preparing care for an adult with Alzheimer’s (still in early stages), what changes can I make now to prepare for the future challenges? Lisa F., Morton, IL

Think of what you can afford to commit later on down the road. The average caregiver can easily spend up to 20 hours (or more) a week caring for someone with this disease. This can obviously cause one to have to quit or cut back on work.  Some basic things you can do now to prepare are:

• Prepare legal documents in advance (any possible future inheritance to be changed
• Align insurance with future needs (review beneficiary arrangements)
• Get in touch with the whole family, get them on board with any plans now if possible
• Investigate, and potentially contact, home health and facility options
• Monitor the disease, be prepared for changes before they are necessary
• Stay informed! Be realistic.  Ask questions and seek out professional guidance

It is important to remember you are not alone. Utilizing tools now can take you a long way in the future.

How should I determine which assisted living options might be best to consider for my parents? -Anonymous, Peoria, IL

The better question in this regard is “what do I need to ask?” The idea here is that you need to ask yourself, your parents, and anyone else involved what needs have arisen already, and where the future will take you. For instance, depending on a diagnosis the answers here could change greatly.

If considering home health care the questions you should ask are things like:

•       A tough question - When should my parents stop driving
•      Who will take care of them
•      Who will pay for it

·         Is home health a long-term or short-term solution

Similar questions can be posed for facilities, and you can find a good deal of information on local facilities at http://www.livingbyyourdesigninc.com/facilities.php

The key to any plan for later years is tailoring to fit your family’s specific needs.  Remember, your parents are the captain of their ship.

In recent posts and articles you have mentioned “preparing legal documents,” what exactly does this mean beyond just assembling a will, and what should I watch out for? -Suzanne K, Peoria, IL

Suzanne,

Jargon and industry terms are sometimes difficult to understand, for many families going through this time in their lives. When we say the term ‘legal documents,’ typically we are referring to Powers of Attorney and a will, or any preparatory legally binding document that gives direction for the future.

Primarily, this includes the following, all of which should be discussed in detail with all parties involved and should only be done through a lawyer:

·         

• Getting a will written that includes advance directives and wishes.
•  Include POA (powers of attorney) for healthcare and finances.
•  In some cases a trust may be in order.

There is a lot to say on this matter, and each family will have different needs. My recommendation is to secure legal advice if there have been changes since you last had legal documents drawn up, and assess where your family’s greatest needs are. 

Question : I have a parent with early to mid-stage Alzheimer’s and am concerned about potential future needs. I have some ideas for how I would like this process to go for my family, but am not sure how or when it is appropriate to bring this up. When is the right time to start talks with my other parent and siblings? -Zachary S. Princeton, IL

This can be a difficult question to pose for families dealing with any chronic illness. Due to Alzheimer’s trademark neurodegenerative properties it can be especially difficult. Although it may be difficult to speak of at this time, the pros to planning for this kind of thing typically outweigh the cons. The outcomes of any crises that arise later are likely to be far worse without a plan in place. If a facility is needed on short notice the family may have little choice where to send their loved one, and will instead have to settle for wherever openings are present. These types of scrambles could lead to you, or your siblings, missing work and dealing with a good deal of unnecessary stress. My advice is to consider what will motivate your other parent or siblings in to action to plan for the what-if situations. These could include the family home, residential accommodations, power of attorney, etc. 

What advice do you have for an adult with children looking to plan for their parent’s final years? -Susan N. Morton, IL

If you are in this sandwich generation (age 45 -55 helping parents and with children at home), then planning now is the best advice to give. Some action steps to take at this time will be sorting out legal, financial, residential, mental and physical healthcare elements prior to a crisis. Engage any siblings you may have in the planning and figure out how to begin involving them now so that one of you is not bearing all future legal and, potentially, financial burdens alone. 

How do I get my parents to listen and act on my suggestions?  They need help and I have been fairly distant and they just won't listen to me.  Deb - East Peoria, IL

This is  great question.  Many times if an adult child and family are actively involved in getting together and helping their parents starting around age 60 or so, parents tend to listen and follow the advise of their adult children more so.  This question is very good and look to my May Column in Healthy Cells to read more. 

QUESTIONS PEOPLE ASK

If dad has good health and mom is having memory problems, how can we best arrange the sale of their home? George - Pekin, IL

The best way to prepare for a future financial event is to have a financial power of attorney in place. Secure legal advice to obtain this document.

My father is on Medicare.  Will Medicare pay for all nursing home services if our family is not able to do so?  Marilyn - Peoria, IL

For (Original) Medicare to pay for skilled nursing home (SNF) services, a your father would need to have been hospitalized as an inpatient for 3 days and then confined in the SNF within 30 days.  Medicare would pay the first 20 days if be receiving a high level of skilled care.  Medicare would continue paying for skilled care with a co-pay as long as 100 days in a benefit period.  Ability to pay is not a factor.

Mom lives with us and has dementia. We would like to attend our daughter's wedding Denver, how and where can we secure care and make sure mom is safe? Ellen - Chillicothe, IL

You have several options, but perhaps the best is to look to an assisted living facility where mom can stay for several weeks while you are gone. You will need to privately pay, but I believe you will find the price fair and about the same as a hotel room.

My brother is in an assisted living and has a long term care policy.  Can i get help to make a claim to help pay for these expenses? Gene - Peoria, IL

The way the LTC claim is presented may be critical in getting a claim which meets criteria paid quickly and correctly.  We can help you examine his situation and help him make claim.

My mother has a small dog that is like family.  Would she be able to keep her dog if she moved to a retirement community? Mary - Canton, IL

Some, but not all, retirement communities allow residents to keep their small pets.  Usually, a dog would need to be 30 lbs or less.

**Disclaimer: Names and places have been changed to protect identity. **

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