Medicare Highlights


On Monday I attended the DC Senior Resource Group (DCSRG) meeting for the second time. The DCSRG is a networking event for people who work with the aging population. It’s held once a month at the Methodist Home church in Northwest DC.

This month, Alfred J Chiplin, Jr. or “Chip,” a senior policy attorney from the Center for Medicare Advocacy, Inc. spoke to the DCSRG about Medicare. I knew Medicare was a complex government program, but WOW…I found out it is even more complicated than what I imagined. Chip was a great teacher and highlighted 20 aspects of the program advocates in aging should know. A couple issues I learned and think are important for readers to know:

  • Enrollment Periods. There is Medicare Part A, Part B, Part D, and the Advantage Plan, all different from Social Security. If that is not complicated enough, plans have various enrollment and disenrollment periods! If seniors miss an enrollment period, they may not have access to coverage AND receive a penalty. lays out the enrollment periods and starting dates of coverage across complex tables.
  • Maintenance Care. Seniors may receive certain therapies (physical, occupational, speech, behavioral) or nursing services if they are improving. This is problematic, because sometimes the goal of care is not to improve functioning in seniors, but to maintain the skills left or to slow deteriorate in other abilities. Thanks to Jimmo V. Sebelius, courts provided a clarification rule requiring Medicare to cover therapy and nursing services for maintenance care. Now, this does not mean that Medicare gladly reimburses these services. In fact, they continually deny claims. Visit the CMA and arm yourself with the information you need and claim what is rightfully yours!
  • Observational Status. Sometimes seniors stay in a hospital, but are not technically admitted. They stay there for “observation.” This is a problem when seniors are discharged to a nursing home. If seniors are not “admitted” to the hospital, Medicare will not cover their nursing home stay because they do not meet “hospital level of care requirements.” If you or your loved on goes to the hospital for “observation” be vigilant about asking nurses and doctors and social workers about these issues to ensure that healthcare is covered. Remember that you are your best advocate. Contact your congressional representatives to end the “observational status” dilemma.
  • Therapy Caps. In order to avoid fraudulent claims, the government puts a cap on the number of hours a patient can receive therapies (physical, occupational, speech). Unfortunately, these caps are low, and like other procedures in our healthcare system, not based on any defined reasons or measures. Thus, caps are “artificially low.” The only way to change this rule is through Congress, who is considering the change, but can’t agree on any thing at the moment.


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