Switching from a Medicare Advantage plan to regular Medicare plan - has anyone had any experience with this for their parent? Pros and cons?
My 94yo mother, who is still of sound mind (short of forgetfulness) insists on aging in place and is house bound. I'm her long-distance caregiver (two hours away and FT job). I travel every other weekend to care for her and her large home. She developed edema and last year was hospitalized twice for cellulitis in her legs. She has had a home health nurse to wrap her legs since, as with her back issues she has trouble keeping her legs elevated; thus, it is difficult to keep the swelling from occurring. The leg wraps are the only solution for her as she can't get compression stockings on, nor can others get them on her because she has little strength in her legs. Recently, continuation of her insurance coverage for this was denied as the nurse's assessment indicated her legs were healed. However, her legs began weeping within 12 hours of the removal of the wraps. After many phone calls to the nursing agency, a re-assessment was completed and the insurance company authorized 8 more weeks of visits through the first week in December. The nursing agency suggested we switch from my mother's current Medicare Advantage plan to regular Medicare, as a regular Medicare plan usually does not require prior authorizations. Has anyone had this experience and how did it work out? Did switching to regular Medicare prove to be a better choice? Thanks for any insight.
SHIP is Senior Health Insurance Program.
They are people that have been trained to help you navigate the various Health Plans and they can help find the one that is best suited for the least cost.
They are not paid by any Insurance Plan so they are not beholden to any of them and they will give you unbiased information.
As others have suggested, time to work through some plans for the future now as it will get worse/harder. And, I would advise getting with a licensed elder care attorney in the State where your mom resides as each State law/regs are different.
There are many "moving parts" to figuring out what is best. But so-called regular Medicare is better overall as it does not have so many impediments to coverage. That said, it will be more expensive. Medicare Part A (inpatient hospital care, and post acute care such as a limited home care or SNF option) does NOT have a premium, but there is a deductible.
Your mom will need Medicare Part B, which covers things like doctor visits and some "B, physician administered drugs such as an infusion." Medicare Part B has a monthly premium. I believe the standard Part B premium is about $175 for 2025. That said, if you mom's adjusted gross income is above a certain amount, the premium might be more. There may also be a "late" Part B premium if one did NOT sign up for Part B when first eligible. This is the Part B Late Enrollment Penalty." Part B has a deductible and a 20% cost sharing, more money.
Your mom will need Medicare Part D for outpatient drug coverage as original Medicare does NOT cover drugs other than those administered in the hospital, in a post acute care facility or in a doctor's office, vaccines too. The premiums for Part D depend on the plan one chooses. First, make sure the outpatient drugs she takes ARE covered by the D plan you are considering. Just do not choose based on the premium.
Medigap (another premium) may cover some of the out of pocket costs and cap out of pocket costs. There are different plans to look at and compare.
You said your mom is "homebound." If she meets the Medicare definition of "home bound" she may be entitled to other regular/traditional Medicare benefits.
If she has other issues -- has end stage renal disease/kidney failure, for example -- she may be entitled to other benefits.
If she meets the definition of "disabled" for Social Security, again she may be entitled to other benefits.
Some states have so-called PACE programs that cover more things and she may be entitled to that.
Lastly, there are various Medicaid-related (for low income folks) possible options if she "spends down."
This is very complex and difficult without proper legal advice. Yes, that too will cost money, but it may give you and her a better understanding to make the right decisions so she gets the best care possible.
Good luck with this
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There are also other magnesium supplements that she could take orally as well.
Medicare: My mother has been on original Medicare since she was 65 and is now 97. She also has a supplemental plan G. Since I have been handling her medical issues, including hospitalizations, surgeries, doctor visits, and now hospice care, she has not paid one penny in medical bills. Not one penny.
Last May I turned 65 and am now also on Medicare. Before deciding on an advantage vs traditional medicare, I did my due diligence and it became clear to me that original Medicare with a supplemental plan is the way to go.
Even though people think that an advantage plan is "free", it's not. You still pay the $174.00 every month - it just goes to an insurance company. And now you've brought another entity who can reject your claims into your medical issues. No thanks. Doctors and hospitals don't have to take Advantage plans from what I understand, but they do have to take Medicare unless they want to pay a penalty.
So I went the same route as my mother with original Medicare and a supplemental plan G through Mutual of Omaha. I am assuming that I will have the same level of payments as my mother if and when I begin to need medical treatment.
Keep another thing in mind. In either plan, CMS will still dictate the number of treatment coverage since the diagnosis code will not change.
(SHIP = Senior Health Insurance Plan)
These are trained counselors and they do not work for any insurance plan so are not beholden to any of them They will look at all the medications, the current plan and compare and find a plan that will work best.
The service is free.
Just do a search for "SHIP counselor in my area" Many Senior Service Centers have one or more but you will have to make an appointment....pretty busy this time of year.
Second I want to emphasize again--and you should be able to check on this--that I don't believe. Medicare, regardless of the kind of plan, will pay indefinitely for someone to come into the home to wrap a person's legs. There are other pros and cons of the different kinds of plans, but the deal-breaker should not be whether or not pre-authorization is required for someone to come in to do the wraps. The result in this situation will probably be pretty much the same.