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By Nancy Burner Esq.

Nancy Burner, Esq.

The Medicare program is administered jointly by the state and federal government. Medicare is available to adults 65 years of age and older, or to anyone under the age of 65 who is entitled to Social Security Disability. 

Medicare provides varying levels of medical coverage, depending on the plan you have. Medicare Part A and Part B, two of the more basic plans, provide coverage for hospitalization stays, rehabilitation, physical therapy, routine doctor visits, and medical equipment. Medicare Part A will also cover the cost of hospice care with a terminal diagnosis of less than 6 months. 

It is important to note that Medicare will not pay for long term services in a facility or services received at home on a long term basis. For example, if you fall and require surgery, you may need rehabilitation in a facility before able to safely return home. In this case, as long as all requirements are met following the hospital stay, Medicare Part A will cover the full cost of the first 20 days in a rehabilitation facility. For days 21-100, there is a co-pay per day if the patient continues to need rehabilitation services. 

If you have a supplemental insurance policy or commonly referred to as a “gap” policy, this may help ease the cost of the daily out of pocket co-pays. After Medicare stops paying, the full cost of the nursing home falls on the patient. This can cost can be upwards of $600 per day.

As you can see, coverage for rehabilitation under Medicare Part A is intended to be short-term. The goal is improvement of acute conditions through rehabilitation and skilled nursing care. While given up to 100 days, patients rarely qualify for this full amount. After admittance to a facility, the patient is evaluated periodically. Once the facility determines that the patient no longer needs skilled care, coverage under the Medicare program ends.

The most important piece to understand is the difference between skilled care and custodial care. Medicare does not cover custodial care. There are many circumstances where the patient does not fall into the category of needing rehabilitative or skilled care, but the family cannot bring their loved one home safely. Medicare does not pay for time to set up a discharge plan. Once Medicare terminates coverage, the patient needs to return to the community or start privately paying for care.

As you enter the arena of Medicare and with unpredictable times, education is key. It is important to meet with your Elder Law attorney to discuss future care plans and options for aging in place successfully.

Nancy Burner, Esq. is the founder and managing partner at Burner Law Group, P.C with offices located in East Setauket, Westhampton Beach, New York City and East Hampton.

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By Leah S. Dunaief

Leah Dunaief

A dear friend of mine just celebrated her 65th birthday this week, and she regards it as a significant number. “How did I get here so fast?” she asks. She also recognizes that she is getting older. That might even be a little scary.

Yes, she is now covered by Medicare. This is both an asset and a shock. When she looks at her new Medicare card, she wonders how this could be. Is she really now eligible for Medicare? Her grandmother was on Medicare, surely not her. But there is her name; the reality is undeniable.

“Well,” she silently acknowledges, “it’s good to have that coverage.” But the sight still stings a bit.

Part of her response is the awareness that she is aging, that she has entered the first phase of the three-part delineation of older age. There is the young-older, from 65-75; then the middle-older, from 75-85; and the third segment, 85-95. Whoever decides and names these demographic groupings seems to have been unable to imagine any group beyond that point. Maybe it should be called “The Beyond Expectations Group.”

With her new realization comes a vow to concentrate on her health and to make the ensuing years hardy ones. She has vowed to pay more attention to her diet, to make better choices concerning what she eats. More fruits and veggies are in store. But no amount of blueberries and kale can eliminate aging. She has now followed through with her long-held intention to work with a trainer. And she is getting a new mattress to help her sleep better.

My friend is doing something helpful for herself. She is turning concerns of aging and the rapid passing of time into better health actions so as to control how she wants to age. Life for her will no longer be just on automatic pilot.

Although there are more older people in America than ever before, aging is fearful for 87% of the population, according to a survey of those turning 65 conducted by Pfizer. It’s called FOGO — fear of getting old.

Why are people afraid of getting old?

There are a number of reasons. Aging can diminish employment prospects. It is a given that older employees earn more than younger newcomers, and while it is illegal to discriminate by age, we all know that such bias exists. It is no wonder, then, that plastic surgeons do face-lifts to combat wrinkles and laugh lines, adjust sagging necks and erase any other evidence of aging. And it is not only women who undergo such procedures. Many men feel the need to blunt evidence of having lived into and past middle age.

People fear losses: of physical ability, of their good looks, of sufficient finances, of memory, of loved ones and consequently of being lonely, and even of their health shortly to be burdened with chronic diseases. Underlying all this is the fear of losing independence.

Interestingly, only 10% in the survey said they were afraid of dying.

Other cultures respect and may even venerate older members of society. Aging can bring people an enhanced sense of gratitude, a calmer demeanor, an awareness of what is truly important, greater ability to resolve conflicts and even an inclination toward forgiveness. Elders are assumed to have accumulated some wisdom just from more years of living and are respected for that.

Of one thing, my friend is sure. When we consider milestones, it seems like the time between them is little more than the blink of an eye. She clearly remembers the details of her Sweet 16 party, the fun of turning 21, her graduation from law school and now suddenly, to be in the Final Frontier is one swift stroke of time after the other. Blink and you are 65. And along comes the recognition that the future is no longer assured.

My friend does not want to go quietly into older age.

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By Nancy Burner, Esq.

Nancy Burner, Esq.

Skilled nursing care is a high level of care that can only be provided by trained and licensed professionals, such as registered nurses, licensed professional nurses, medical directors, and physical, occupational, and speech therapists. 

Skilled care is short-term and helps people get back on their feet after injury or illness. Skilled nursing facilities are residential centers that provide nursing and rehabilitative services to patients on a short-term or long-term basis. Examples of the services provided at a skilled nursing facility include wound care, medication administration, physical and occupational therapy, and pulmonary rehabilitation.

Generally, patients who are admitted to skilled nursing facilities are recovering from surgery, injury, or acute illness, but a skilled nursing environment may also be appropriate for individuals suffering from chronic conditions that require constant medical supervision. If you or a loved one is interested in using Medicare for skilled nursing, though, there are specific admission requirements set by the federal government:

• The individual has Medicare Part A (hospital insurance) with a valid benefit period. The benefit period will start from the date of admission to a hospital or skilled nursing facility and last for up to 60 days after the end of the stay.

• The individual has a qualifying hospital stay. This generally means at least three in- patient days in a hospital.

• The doctor has recommended skilled nursing care for the individual on a daily basis. The care must be provided by skilled nurses and therapists or under their supervision and should be related to the condition that was attended to during the qualifying hospital stay.

• The individual is admitted to a skilled nursing facility that is certified by Medicare. A skilled nursing facility must meet strict criteria to maintain its Medicare certification.

Usually, the skilled nursing care services covered by Medicare include the room charges, provided that it is a semi-private or shared room, meals at the facility, and any nutritional counseling, as well as costs of medication, medical supplies, medical social services, and ambulance transportation. It also covers rehabilitative services that are required to recover from the condition, such as physical therapy, respiratory therapy, and speech therapy.

Medicare generally offers coverage for up to 100 days of treatment in a skilled nursing facility. Note that if the patient refuses the daily skilled care or therapy as recommended by the doctor, then the coverage by Medicare may be denied for the rest of the stay at the skilled nursing facility. Many patients are advised that they will not get the full 100 days of Medicare benefits because they had reached a “plateau” or that they failed to improve. This is known as the Improvement Standard and was a “rule of thumb” used to evaluate Medicare patients. 

Applying the Improvement Standard resulted in the denial of much needed skilled care for thousands of Medicare patients. The denials were based on a finding that there was no likelihood of improvement in the patient’s condition. This standard ignored the fact that the patients needed skilled care in order to maintain their current state of health and to prevent them from deteriorating. More often than not, if the patient was not improving, Medicare coverage was denied. While this standard was widely used, it was inconsistent with Medicare law and regulations.

A court case brought by Medicare beneficiaries and national organizations against the Secretary of Health and Human Services (Jimmo v Sebelius) sought to change this. The plaintiffs argued that even though the term “plateau” does not appear in the Medicare regulations, it is this term that is often used and relied upon to deny coverage. The appropriate standard should be: will the covered services “maintain the current condition or prevent or slow further deterioration,” not whether the individual was showing signs improvement.

As a result of this litigation and the settlement on Jan. 24, 2013, patients should be able to continue receiving services provided by Medicare, even where improvement in the patient’s condition cannot be documented. However, the old standard continues to be used. Patients and their advocates should educate themselves on the correct standard to make sure coverage is not cut prematurely.

Nancy Burner, Esq. is the founder and managing partner at Burner Law Group, P.C with offices located in East Setauket, Westhampton Beach, New York City and East Hampton.

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Medicare and Medicaid are both invaluable programs that can be used to cover various medical and custodial expenses.

By Nancy Burner, ESQ.

Nancy Burner, Esq.

This is a question we receive often. Navigating the maze of healthcare coverage can be confusing.nFor starters, a brief overview of the programs will help to demystify and clear some of the confusion. Medicare is a federal government program first implemented in 1965 as part of the Social Security program to provide health coverage to persons 65 or older and in some cases younger so long as they can show a qualifying disability.

Coverage through Medicare is broken down into sections, Part A is considered hospital insurance and covers inpatient hospital care, rehabilitation in a skilled nursing facility, hospice services, lab tests surgery and home health care. There is no premium for Part A provided you or your spouse have worked at least forty quarters and paid into the program.

It is important to note that the coverage for skilled nursing is limited to the first twenty days in full and then there will be a co-pay of $167.50 per day for days twenty-one through one hundred. A person must continue to qualify based on their skilled need throughout the hundred-day period for Medicare to continue cover. There is no guarantee that a person will receive all hundred days of coverage. Custodial care and extended stays will not be covered by Medicare.

Part B covers doctors and other health care providers’ services and outpatient care. The monthly premium for Part B is typically $134.00 but can vary depending on the person’s income. Part D provides cover with respect to prescription drugs. This is a stand-alone drug plan that can assist in reducing prescription drug costs. Finally, Medicare Part C, is also known as the Medicare Advantage which are optional plans offered by Medicare-approved private companies which replace Medicare Part A and B.

Unlike Medicare, Medicaid is a means tested program and is state specific. Medicaid can provide coverage for a personal care aide at home through the Community Medicaid program or can also cover an extended custodial stay at a skilled nursing facility through the Chronic Medicaid program. In order to be financially eligible to receive services at home, an applicant for Community Medicaid cannot have liquid non-retirement assets in excess of $15,150.00.

Also exempt is an irrevocable pre-paid burial, retirement assets in an unlimited amount so long as the applicant is receiving monthly distributions and the primary residence. With respect to income, an applicant for Medicaid is permitted to keep $837.00 per month in income plus a $20.00 disregard. However, where the applicant has income which exceeds $862.00 threshold, a Pooled Income Trust can be established to preserve the applicant’s excess income.

Even though there is a resource limit of $15,150.00, there is no “look back” for Community Medicaid. In other words, both the income and asset requirements can be met with a minimal waiting period allowing families to mitigate the cost of caring for their loved ones at home.

With respect to coverage in a nursing facility, Chronic Medicaid can cover an extended custodial stay at a nursing facility. In New York, an applicant applying for Chronic Medicaid will be required to provide a sixty-month lookback with respect to all financial records, including bank statements and tax returns. Unlike Community Medicaid, an applicant for Chronic Medicaid will be penalized for any monies transferred out of the applicant’s name during the sixty-month lookback except for transfers to exempt individuals, including to but not limited to spouse or disabled child. If your loved one requires long term nursing home placement, it is imperative to consult and Elder Law attorney in your area to discuss how to preserve the maximum amount of assets.

Medicare and Medicaid are both invaluable programs that can be used to cover various medical and custodial expenses. Understanding the difference and what each program covers will allow you to be an advocate for yourself or a loved one.

Nancy Burner, Esq. practices elder law and estate planning from her East Setauket office.

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Christina Loeffler, the co-owner of Rely RX Pharmacy & Medical Supplies in St. James, works at one of the few non-major pharmacies in the county participating in the program to give low to no cost Narcan to those with prescription health insurance coverage. Photo by Kyle Barr

By Kyle Barr

The opioid crisis on Long Island has left devastation in its wake, and as opioid-related deaths rise every year, New York State has created an additional, more affordable way to combat it. To deal with the rash of overdoses as a result of addiction, New York State made it easier for people with prescription insurance to afford Naloxone, a common overdose reversal medication.

On Aug. 7, New York Gov. Andrew Cuomo (D) announced starting Aug. 9 that people with prescription health insurance coverage would be able to receive Naloxone, which is commonly referred to as Narcan, for a copay of up to $40. New York is the first state to offer the drug for such a low cost in pharmacies.

Narcan kit are now available for low to no cost at many New York pharmacies. File photo by Rohma Abbas

“The vast majority of folks who have health insurance with prescription coverage will be able to receive Naloxone through this program for free,” said Ben Rosen, a spokesperson for the New York State Department of Health.

Before the change, the average shelf cost of Narcan, which is administered nasally, was $125 without prescription with an average national copay of $10. People on Medicaid and Medicare paid between $1 and $3, Rosen said.

This action on part of the state comes at a critical time. Over 300 people from Suffolk County died from opioid-related deaths in 2016, according to county medical examiner records. On Aug. 10, President Donald Trump (R) declared the opioid issue a national emergency, meaning that there is now more pressure on Congress to pass legislation to deal with the crisis, as well as a push to supply more funds to states, police departments and health services to help deal with the problem.

The drug is available in over 3,000 pharmacies across New York and well over 100 pharmacies in Suffolk County. This includes all major pharmacies like CVS Health, Walgreens and Rite Aid, but also includes a few local pharmacies that already participate in the state Aids Drug Assistance Program and Elderly Pharmaceutical Insurance Coverage and Medicaid, according to Kathy Febraio, the executive director of the Pharmacists Society of the State of New York, a not-for-profit pharmacists advocacy group.

The program is only available for people who either have Medicare, Medicaid or health insurance with prescription coverage. Otherwise, officials said that those who lack insurance who need access can get it through a number of free Narcan training courses.

“We think that anything that can have an affect on this crisis is a good thing,” Febraio said. “This will certainly help. We need anything that will get Naloxone into the hands of those who need it.”

While Suffolk County Legislator and Presiding Officer DuWayne Gregory (D-Amityville) likes the idea of additional access to Narcan, he is skeptical about whether those who get it know how to properly administer it.

Narcan kits are now available for low to no cost at many New York pharmacies, like at Rely RX Pharmacy & Medical Supplies in St. James. Photo by Kyle Barr

“You don’t need a PHD to know how to use it, but there is some training that would help people be more comfortable, such as how to properly use it in an emergency situation and how to store it so that it is accessible while making sure children can’t get their hands on it,” he said. “Unfortunately the epidemic is so wide spread. Everyone knows someone who is affected.”

Christina Loeffler, the co-owner of Rely RX Pharmacy & Medical Supplies in St. James, one of the few non-major pharmacies in the county participating in the program, said though the business has not yet received many calls for Narcan, the state requires pharmacists to demonstrate how to use it.

“You have to counsel the patient and show them how to use it,” she said. “We were showed videos, we were given kits to practice on before we were certified to do it. I feel like it’s a good thing that they’re doing it.”

The county currently provides numerous Narcan training courses for locals, where they receive training and free supplies of the life-saving drug. Suffolk County Legislator Sarah Anker (D-Mount Sinai) said that she will be co-hosting a free Narcan training course Oct. 5 at Rocky Point High School with support from the North Shore Youth Council.

“They absolutely need to be trained,” she said. “Narcan is almost a miracle drug — it brings people back from death. However, people need to know what they’re doing so that it is administered correctly.”

Check on the New York State Department of Health website’s opioid overdose directories section for a full list of participating pharmacies.

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By Nancy Burner, ESQ.

Nancy Burner, Esq.

As you may know, Medicare will pay for a patient to receive rehabilitation in a facility if they have a qualifying stay in a hospital: being admitted to the hospital for two nights. The first 20 days of rehabilitation are completely covered by Medicare. The 21st through the 100th day will have a co-payment of $161 per day. This co-payment may be covered by a Medicare supplemental plan.

However, it is important to note that while there is a potential to receive 100 days of rehabilitation, it may be determined that rehabilitation is no longer needed and the discharge will be set up.

The facility is required to give written notice that they believe Medicare will no longer cover the patient. This comes as a “Notice of Medicare Non-Coverage.” This notice gives the patient the right to appeal the decision. In order to make an effective appeal, it is important to know the appropriate standard that the law requires the facility use in making a determination.

That standard was inconsistent with Medicare regulations. The true standard is whether the patient needs the rehabilitation to maintain activities of daily living.

In 2011, a federal court case was decided on this issue. In that case, Medicare skilled nursing service recipients challenged the failure to improve the standard. The settlement agreement by the parties rejected the failure to improve the standard and stipulates that the standard for terminating services is not whether the patient’s condition is likely to improve but rather whether the condition will worsen if services are terminated.

Therefore, skilled services should be continued so long as skilled therapies are needed to maintain the patient’s ability to perform routine activities of daily living or to prevent deterioration of the patient’s condition. This represents the current legal standard for denying skilled nursing coverage under Medicare.

Even though this issue was settled by the courts years ago, many patients are finding it is not being followed by facilities. It is important for the patient and their advocates to know the proper standard so they can make an appropriate appeal.

On Feb. 2, 2017, a new federal court decision stated that the standard is established but it is not being adhered to by facilities. The decision is forcing an educational campaign to be enacted so professionals at facilities and individual Medicare recipients are aware of the appropriate regulations. The plan will include a Centers for Medicare and Medicaid Services website dedicated to this issue and the explanation of the appropriate standard.

Receiving the maximum amount of rehabilitation days possible is the right of all Medicare recipients.

Nancy Burner, Esq. practices elder law and estate planning from her East Setauket office.

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John T. Mather Memorial Hospital in Port Jefferson. File photo from Mather Hospital

No one wants to be sick enough to require a hospital visit, but North Shore residents learned last month they live near three of the best facilities in the Long Island/New York City area if that day should come.

Data compiled by Medicare based on patient surveys conducted from April 2015 through March 2016 and released in December ranked John T. Mather Memorial Hospital and St. Charles Hospital in Port Jefferson, as well as Stony Brook University Hospital, among the top seven in overall rating, and the top nine in likelihood patients would recommend the hospital to a friend or family member.

A patient receives care at John T. Mather Memorial Hospital in Port Jefferson, one of the top hospitals in the Long Island/New York City area based on patient survey data. File photo from Mather Hospital

Overall patient satisfaction ratings were based on recently discharged patient responses to survey questions in 10 categories, including effectiveness of communication by both doctors and nurses, timeliness of receiving help, pain management, cleanliness and noise level at night, among others.

Mather finished behind just St. Francis Hospital in Roslyn of the 27 hospitals considered in the New York/Long Island area in their overall rating. St. Charles ranked sixth and Stony Brook seventh. Mather was also the second most likely hospital for a patient to recommend to a family member or friend, with St. Charles and Stony Brook coming in eighth and ninth places, respectively. St. Francis also topped that category.

Stu Vincent, a spokesperson for Mather, said administration is proud to be recognized for its quality.

“The driving force behind everything we do at Mather is our commitment to our patients, their families and the communities we serve,” he said. “We know people have many choices in health care and we continually strive to ensure that our hospital exceeds their expectations through our employees’ commitment to continuous quality and patient satisfaction improvement.”

A spokesman from St. Charles expressed a similar sentiment.

“At St. Charles, the quality of care that we provide to our patients is first and at the center of everything we do,” Jim O’Connor, executive vice president and chief administrative officer at St. Charles said in a statement. “That commitment to quality is evidenced by these wonderful patient satisfaction scores and the successful number of high level accreditations St. Charles received recently.”

Stony Brook hospital spokeswoman Melissa Weir emailed a statement on behalf of hospital administration regarding its rank among other area facilities.

“We are constantly looking for ways to improve, and are continuously developing new approaches to ensure that our patients have the best experience while they are in our care,” she said. “One of our goals is to achieve top decile performance with a focus on matters such as improving communication, reducing noise, addressing pain management and implementing nurse leader hourly rounding and hourly comfort checks.”

Mather’s ratings were at or above average for New York and nationwide in nearly every category as well as the likelihood to be recommended by a patient. St. Charles beat New York averages in nearly every category and was above the national average in likelihood to be recommended. Stony Brook was also above average compared to the rest of the area in most categories.

All three hospitals received their highest scores in communication by doctors and nurses, along with their ability to provide information to patients for effective recovery at home. All three hospitals were given their lowest ratings in noise levels at night and in patient’s understanding of care after leaving the hospital.

For a complete look at the ratings visit www.medicare.gov/hospitalcompare.

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