CMS Issues Final Drug
Benefit Regulations
Written
By:
Jeffrey A. Marshall
, Certified Elder Law Attorney*
The
Centers for Medicare and Medicaid Services (CMS) has issued final
regulations governing the Medicare Drug Benefit and the Medicare Advantage
Program as required by the Medicare Act of 2003. The rules will implement
the Medicare drug benefit that becomes available on
January 1, 2006
.
The final rules require drug plans to provide
“adequate coverage of the types of drugs most commonly needed” by
Medicare beneficiaries. But,
plans will be permitted to establish formulary lists of preferred drugs
and to refuse to pay for drugs not on the list. However, plans will have
to cover specific drugs if the patient’s doctor certifies them as being
medically necessary for the patient.
Each Medicare drug plan is likely to establish a list
of pharmacies that beneficiaries will use to obtain their discounts.
Expanded utilization of mail order pharmacies can be anticipated.
One area of concern has been the over 6 million
people, including many nursing facility residents, who are covered by both
Medicare and Medicaid. These “dual eligibles” currently receive their
drug coverage through Medicaid. Under the terms of the Medicare
Act, Medicaid coverage for dual eligibles will cease on
January 1, 2006
and they will have to be enrolled in one of the Medicare
prescription drug plans. With
the release of the regulations, Mark McClellan, administrator of CMS,
stated that there would be “no gap in coverage” and that dual
eligibles will be automatically enrolled in a Medicare drug plan this
fall.
In addition to drugs, the regulations deal with many
of the other complicated issues created by the Medicare Act of 2003. They
create new regional Medicare Advantage (MA) programs for Medicare
preferred provider organizations, with 26 regions.
Pennsylvania
and
West Virginia
constitute one of these regions (MA Region 6). An MA Regional plan must
operate in all areas of the region which should help ensure availability
in rural areas. The rules also offer significant tax incentives to
employers and unions to continue drug coverage for their retirees.
The regulations are immensely complex, covering 1500
pages. Administrator McClellan said the government will spend $300 million
this year to educate consumers about the various options available to
them.
The Associated Press reports that business groups are
praising the new rules. "Moving swiftly on these prescription drug
rules will benefit
America
's seniors," said Bruce Josten, Executive Vice President of the U.S.
Chamber of Commerce.
Consumer advocates have been more critical. The
Center for Medicare Advocacy expressed disappointment that CMS did not
address the complexity of the Medicare prescription drug (Part D) program
in the final regulations. This
complexity was a key concern of consumer advocates.
“By continuing to allow Part D plans great
flexibility to design their own benefit structure,” said Judith Stein,
Executive Director of the Center, “CMS has increased the difficulties
that Medicare beneficiaries will have in determining the best course for
them to take.”
“As we have seen with the discount drug cards, when
comparisons among cards become too difficult, Medicare beneficiaries do
not participate in the program, even if they would benefit by doing so,”
said Ms. Stein. “We fear that the most vulnerable beneficiaries - those
with multiple chronic conditions, those with diminished capacity, those
with limited English proficiency - will be unable to navigate the system
CMS has devised, and therefore will not take advantage of the prescription
drug coverage they require.”
Medicare prescription drug enrollment for low income
Medicare beneficiaries is anticipated to begin this summer, with general
enrollment beginning in November.
The final regulations are available online through
the CMS website.
http://www.cms.hhs.gov/medicarereform/pdbma/pdp.asp.
For more information:
Associated Press article “Medicare Issues
Prescription Drug Rules”
http://seattlepi.nwsource.com/national/apscience_story.asp?category=1500&slug=Prescription%20Drugs.
Pacificare (a large health insurer) comments on the
final regulations:
http://www.prnewswire.com/cgi-bin/stories.pl?ACCT=109&STORY=/www/story/01-21-2005/0002869951&EDATE=.
Marshall & Associates
analysis of the Medicare Act of 2003: http://www.paelderlaw.com/prescriptiondrug.html.
Center for Medicare Advocacy press release:
http://www.medicareadvocacy.org/Media_PR_CMSFailsToAddressComplexity.01.20.05.htm.
Attorney Marshall can be contacted at webmail@paelderlaw.com
or at 1-800-401-4552
________________________________________________________________________________
Medical
House Calls Now More Readily Available in NEPA
Written
By: Marshall & Associates’ Attorney Kevin Grebas and Planning
Specialist Jerry Petro
Do
you know someone who needs medical care but is unable or unwilling to make
the trip to the doctor’s office? Well,
you may be surprised to learn that some doctors still make house calls.
Several companies and organizations across the country have begun
offering this service in response to the growing number of homebound
senior citizens who are in need of healthcare services.
Here in
Northeastern Pennsylvania
, HealthEssentials offers medical house calls to senior
citizens who are unable to leave their homes.
Dr.
Fran
k Schell and a team of nurse practitioners can provide health care
services to senior citizens right in their own homes.
They can work with an individual’s existing primary care
physician or, if an individual does not have one, Dr. Schell can be
designated as the primary care physician.
This service can be extremely beneficial to seniors who are unable
to visit their doctor because they are too frail or for those who have no
means of transportation.
Most primary care services that individuals would
normally receive at a doctor’s office can now be provided at home
through HealthEssentials.
These services include physical exams, diagnostic testing, ongoing
preventative care, prescription management and medication management.
Home visits can be covered by Medicare Part B, Medicaid, or other
private insurance, the same as a visit to the doctor’s office.
In addition to the services provided to senior
citizens in their homes, HealthEssentials also works with
long term care facilities to provide geriatric clinical services to
residents. To find out more
about the services provided by HealthEssentials, you can
contact them at (570) 287-4507 or 1-888-505-8900 or on the web at www.healthessentials.com.
Attorney Grebas can be contacted at kgrebas@paelderlaw.com
and Jerry can be contacted at jpetro@paelderlaw.com
or at 822-6919.
________________________________________________________________________________
Federal Tax Credit
for Dependent Elder Care Expenses
Written
By: Marshall & Associates’ Planning Specialist Perry Landon
If
you are paying for household and dependent care expenses so that you can
be gainfully employed, you may be able to claim a personal income tax
credit for a portion of those expenses. The expenses must be for the care
of one or more qualifying individual for whom you maintain a household.
A qualifying individual includes a dependent (someone for whom you
paid for more than ½ of his/her support) who is incapable of self care.
The credit is 35 percent of employment-related
expenses and is reduced by 1 percentage point, but no more than 15
percentage points, for each $2,000 of adjusted gross income (AGI) in
excess of $15,000. So, if the
taxpayer’s AGI exceeds $43,000, the applicable percentage is 20 percent.
The maximum employment related expenses that may be counted in
calculating this credit is $3,000 for one qualifying individual and $6,000
for two qualifying individuals. The maximum credit for one qualifying
individual would be $1,050 ($2,010 for two qualifying individuals), if the
taxpayer’s AGI is $15,000 or less. The
minimum credit for one qualifying individual would be $600 ($1,200 for two
qualifying individuals), if the taxpayer’s AGI exceeds $43,000.
Note that these credit amounts and income requirements may be
adjusted in future years.
There
are several limitations and exceptions that might also apply in your
specific case, so it is advisable to get the advice of an experienced tax
preparer to determine your eligibility for this credit.
Perry
can be contacted at plandon@paelderlaw.com
or at 1-800-401-4552
________________________________________________________________________________
The Probabilities of Needing Nursing Home
Care
Written
By:
Jeffrey A. Marshall
, Certified Elder Law Attorney*
Have you ever wondered how likely it is that you will some day be in a
nursing home? According to a
recent study, 44% of individuals who turned 65 in the year 2000 will spend
some time in a nursing home during their remaining lives; 32% will spend
three months or longer; 23%
percent will be in a nursing home for over a year;
and 8% will spend five years or longer in a nursing facility.
These probabilites will increase slightly in the future as a result
of the increasing life spans. The
older you are, the higher your probability of spending some time in a
nursing home.
A slight majority of
elderly nursing home residents are over age of 85. The average length of
stay of elderly nursing home residents is 870 days with females more
likely to spend a longer time there than males.
Source:
Brenda C. Spillman and James Lubitz,
“New Estimates of Lifetime Nursing Home Use: Have Patterns of Use
Changed?” Medical Care, Vol. 40, no.10 (2002); Congressional
Bud
get
Office, Financing Long Term Care for the Elderly, April 2004.
Attorney
Marshall can be contacted at webmail@paelderlaw.com
or at 1-800-401-4552
________________________________________________________________________________
PACE/PACENET Streamlines Application
Process
Written
By: Melissa Bottorf, Director of Public
Ed
ucation
In
an effort to make it easier for
Pennsylvania
’s elderly to take advantage of PACE and PACENET benefits, program
officials have streamlined the application process for 2005.
Now seniors simply need to complete an application, including a
signature that the information provided is accurate. They are no longer
required to provide documentation of their age, residence or income.
Although less paperwork is required, the programs have partnered
with a variety of other agencies, including the US Social Security
Administration and the Pennsylvania Department of Revenue to help verify
applicants’ information. Since it is sometimes cumbersome for seniors to
locate this documentation and it can untimely delay their enrollment, PACE
and PACENET officials are hoping the simplified process will encourage
more seniors to apply.
According to Pennsylvania Secretary of Aging, Nora
Dowd Eisenhower, “This change is designated to make it easier for
existing enrollees to remain eligible for coverage and for new enrollees
to join.” If you would like
more information on PACE or PACENET, please visit their website at http://www.aging.state.pa.us/aging/cwp/view.asp?a=293&Q=173876
Melissa can be contacted at mbottorf@paelderlaw.com
or at 570-321-9008.
________________________________________________________________________________
Wilkes-Barre
Staff Volunteers at
Luzerne
County
SPCA
Last
week our
Wilkes-Barre
office staff volunteered at the
Luzerne
County
SPCA
.
They spent the afternoon walking dogs, feeding the
animals at the shelter and helping the staff with clean-up.
According to Marshall & Associate’s Attorney Kevin Grebas,
“This was an enjoyable and rewarding experience and we are looking
forward to doing it again.”
If you would like more information about the pets
that are available for adoption, their PAWS to Help-Capital Campaign or
how your group can volunteer, please contact the
Luzerne
County
SPCA
at www.dogsaver.org/spcaluz/
or at 825-4111.
____________________________________________________________________________
In the Community…
The professional staff of Marshall and Associates will be presenting to
the following groups and organizations over the next couple of weeks.
Many of these events are open to the public.
If you would like more information or would like to schedule
someone to speak at your group, please contact Melissa at 321-9008 or at mbottorf@paelderlaw.com
-Health South
will be holding an open house at their new Lock Haven facility on January
27th from
3:00-6:00PM
. Planning Specialist Lisa
Barner and Attorney Matthew Parker will make a presentation on How
to Pay for Long Term Care at
4:00PM
.
-
Attorney Kevin Grebas will be participating in a panel discussion about the New Medicare Drug Discount
Cards at the Hampton House
on February 2nd from
2:00PM-3:00PM
.
- Attorney Matthew Parker will be speaking to the Montoursville
Lioness Club on February 14th about Mistakes
Retirees Make. The
speech will begin at
7:00PM
.
-The
Catawissa
Senior
Center
is offering a presentation on Living
Trusts and Financial Abuse of the Elderly on
February 16th, 2005
from
10:30AM-11:15AM
. Attorney Matthew Parker from
Marshall & Associates will be the speaker.
________________________________________________________________________________
Marshall & Associates Now Offering
FREE In-Office Workshops
Marshall
& Associates is now offering free workshops for seniors, their
families and professionals who want to know more about paying and planning
for long term care. The
workshops are held in our
Williamsport
and
Wilkes-Barre
offices and last about an hour. These
informal discussions with our planning experts are a great opportunity to
learn about the options available to pay for care.
Reservations
are suggested, but not required. SIGN
UP ONLINE or call 1-800-401-4552 for
more information or to reserve your spot.
________________________________________________________________________________
Back
issues of The
Elder Care Law Alerts
are available on our website.
You
can even search our site by a keyword
or phrase!
________________________________________________________________________________
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_________________________________________________________________________
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Law Alert,
simply send your request to:
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________________________________________________________________________________
*Attorney
Marshall
is certified as an
Elder Law Attorney by the National Elder Law Foundation under
authorization from the Pennsylvania Supreme Court
© 2000-2005
Marshall & Associates www.paelderlaw.com
