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RX Medicare Drugs

What is the Medicare donut hole?

By Hook Law Center

The Medicare donut hole is the coverage gap that is within the majority of Medicare Prescription Drug Plans. There is a short-lived restriction on what drugs most plans will cover. The coverage gap does not apply to everyone. It starts after you and your drug plan spend a specific amount purchasing covered medications.

For the year 2016, you are in the coverage gap when you and your plan have spent $3,301 on covered medications. This figure is subject to change every year. In addition, those who have Medicare, and who receive additional assistance with payment of Part D costs will not be included in the coverage gap.

Upon reaching the coverage gap in 2016, you will pay a maximum of 45 percent of the plan’s cost for brand-name prescription drugs that are covered. You will get these savings if you purchase your prescription drugs at a pharmacy or place an order by mail. Even though you will pay a maximum of 45 percent of the price for the brand-name prescription in 2016, 95 percent of the price will be considered out-of-pocket cost that will help you leave the coverage gap.

This figure represents the 45 percent that you pay plus the 50 percent manufacturer discount payment. Your out-of-pocket costs do not include the amount the drug plan contributes toward the cost of the drug, or 5 percent, and the amount the drug plan contributes toward the dispensing fee, or 55 percent of the fee.

In 2016, Medicare will pay 42 percent of the cost of generic drugs during the coverage gap. You will pay the remainder, or 58 percent of the cost. The amount you pay for generic drugs during the coverage gap will be reduced every year until it is 25 percent in 2020. The coverage for generic drugs operates in a different manner from the way in which the discount for brand-name drugs works. With respect to generic drugs, only the amount you pay will be applied toward helping you out of the coverage gap.

Posted on Thursday, July 28th, 2016. Filed under Medicaid, Newsletter.

Understanding a Resident’s Transfer and Discharge Rights under the Nursing Home Reform Act

By Shannon Laymon-Pecoraro, CELA

One of the most frequent issues I face revolves around the discharge of a resident from a nursing home. Often times, an agent or advocate visits my office with a concern, because their loved one is being discharged from the nursing home, and they want to assess what their options are. The good news is that the nursing home cannot just kick a resident out of the nursing home.

A common discharge is related to a loss of Medicare coverage for rehab or skilled nursing care. Under Medicare rules, coverage of rehab services will not extend beyond day 100 and will be cut short due to a refusal to participate in therapies or if daily skilled care is no longer necessary. However, what most facilities fail to explain to the residents and their advocates is that they have the option to remain in the facility, and the nursing home may only involuntarily discharge under a set of parameters as set forth under the Nursing Home Reform Act. Specifically, a nursing home must allow a resident to remain in the facility unless one of the following conditions is met:

  1. the resident’s welfare cannot be met in the facility;
  2. the resident no longer needs the services provided by the facility;
  3. the safety of individuals in the facility is endangered;
  4. the health of individuals in the facility would otherwise be endangered;
  5. the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility; or
  6. the facility ceases to operate.

And, even under those circumstances, the facility is still responsible for the development of a safe-discharge plan. Specifically, a facility is responsible for developing a post-discharge care plan that assesses the continuing care needs and development of a plan designed to ensure the individual’s needs will be met after discharge from the facility into the community.

All too frequently, we receive a statement from a discharge planner that the “safe-discharge plan” includes going to an assisted living facility or returning home with private duty staff to assist with 24/7 care. The problem; however, is that the resident may not be able to afford either of those options, and as a result, would not be safe alternatives to the nursing home. Not only has the nursing facility not informed the resident of his or her right to remain at the facility under private pay (or that Medicaid may be able to assist with paying for care), but has failed to consider whether the “safe-discharge plan” is a viable option.

The question then becomes what is the motivation to discharge a patient. It is simple– the nursing home is a business. Most nursing homes prefer Medicare reimbursement or private pay over Medicaid reimbursement to protect the financial stake of the company. Furthermore, most nursing homes prefer residents who do not have extraneous care needs or advocates that are determined to present a problem to a nursing home.

So, you are probably wondering what you can do in light of an improper discharge:

  1. Appeal the discharge. If you feel that your loved one still requires skilled nursing care or is otherwise being improperly discharged, you may appeal the decision. The facility is required to provide you with a statement pertaining to your right to appeal with the discharge notice.
  2. Demand bill. If you disagree with a facility’s decision of coverage, you may request that the facility submit the bill to Medicare even when the facility believes that services will not be covered by Medicare. The facility cannot bill the beneficiary for the disputed charges until the Medicare fiscal intermediary issues a formal claim determination. If the determination is unfavorable, you should be prepared to pay for the expense.
  3. Find an alternative source for payment. Understand that your loved one’s stay in the nursing home will not be covered by Medicare as of day 101 of institutionalization. If your loved one cannot afford the private pay rate, act promptly to develop a plan for long-term payment in facility. It is imperative that you determine whether an application for Medicaid is necessary, and that the necessary planning for Medicaid, and the submission of an application, occur prior to the expiration of the Medicare covered period.
  4. Investigate bed certification. Many facilities will inform a resident that they do not have any more Medicaid beds available, despite the fact that most facilities have dually-certified beds. What this means is that if you are currently in a bed, they must allow you to stay in the bed even if you are on Medicaid – the number of “Medicaid beds” is most often determined by the facility itself for budgetary purposes.
  5. Be Prepared for a Hospital Discharge. A facility may have the resident admitted to a hospital on in-patient status and deny readmission. Since Virginia Medicaid does not pay for a bed hold, you should consider privately paying for a bed hold.
  6. Do not sign in an individual capacity. If you are an agent for the resident, you should never sign the nursing home admission documents in your personal capacity, and the nursing home cannot require you to sign as a responsible party. Instead, you should clarify, in writing that you are signing on behalf of the resident.

Seek an experienced advocate. If you feel something isn’t right, you should seek someone experienced with resident rights.

Kit KatAsk Kit Kat – Helping Feral Cats

Hook Law Center:  Kit Kat, what can someone do to help feral cats which may be living in a neighborhood?

Kit Kat:  Well, there are some things which can be done, but you will need help from your community. At least, that is what is suggested in a recent article in the All Animals magazine published by the Humane Society of the United States (HSUS). In that article, it is suggested that the person spearheading the effort must first talk to their neighbors and get their input. If one person just captures a few cats with traps, there may be many more out there who will continue breeding, and the situation will not become manageable. Let me provide an example, so you will see what I mean.

Beth McNulty, an operations manager with the HSUS, who lives in rural Monrovia, MD noticed in 2010 a spike in the number of stray cats which were wandering through her yard. Occasionally, she would see one or two, but this was almost a dozen. She herself had 3 indoor cats, and one was just recovering from a spraying behavior, so she was afraid to take in anymore cats would set hers off again. In her sleuthing, she discovered that the cats had been living in a nearby junkyard which was being cleaned out. The cats fled in the confusion. To make a long story short, she discovered that the best way to start the process of helping the feral cat colony was to involve her neighbors. Their awareness and help resulted in a neighborhood-wide trapping effort. Thirty older cats and older kittens were sterilized, and returned to their former abode (the now clean junkyard). Three small kittens were placed with a rescue group. McNulty hasn’t seen another addition to the clan yet. This approach of capturing feral cats, sterilizing them, and returning them to live on their own is known as TNR (trap-neuter-return). It appears to be a humane way of caring for them without resorting to euthanasia.

You can tell if a feral cat has been sterilized by a clipped ear lobe. That is done after the sterilization, so all will know. How can you tell the difference between someone’s pet who has just gotten lost or a feral cat? Usually, the feral cat will not eat in the presence of a human. The feral cat will only eat after the human has walked away. So, be aware of stray cats in your community. There may be a way to humanely maintain them there, as they live out their lives.(Julie Falconer, “The Outsiders-How to Help your Neighborhood’s Felines,” All Animals, July/August 2016, p. 16-21)

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Hook Law Center encourages you to share this newsletter with anyone who is interested in issues pertaining to the elderly, the disabled and their advocates. The information in this newsletter may be copied and distributed, without charge and without permission, but with appropriate citation to Hook Law Center, P.C. If you are interested in a free subscription to the Hook Law Center News, then please telephone us at 757-399-7506, e-mail us at or fax us at 757-397-1267.

Posted on Tuesday, July 26th, 2016. Filed under Senior Law News.

What personal representatives of estates need to know

By Hook Law Center

Personal representatives, or executors, of estates need to be aware of the procedure that is used to probate an estate with a will. The executor who is designated in the will must make an appointment with the probate division to probate the will and become qualified to serve as executor. To do this in Virginia, the executor is required to be a resident of the state, but statutes will permit out-of-state residents to become eligible. When the executor is not a Virginia resident, a resident of Virginia is required to go with the executor to the Probate Office to either co-qualify or be assigned as a resident agent.

If the executor does not desire to serve, the executor is required to produce a notarized statement declining the appointment. Any alternates mentioned in the will are then considered. If no alternates are mentioned, or if any alternates relinquish the right to serve, then an administrator c.t.a. will need to be appointed.

If the designated executor is deceased, the alternate executor or administrator c.t.a. has to produce a copy of the death certificate at the probate appointment. If the executor would like to be removed, then the executor is required to file a petition for a removal, along with a filing fee.

The basic responsibilities of an executor are:

  • to inform interested parties of probate;
  • filing an affidavit or notice;
  • filing an inventory;
  • filing a settlement of accounts or statement instead of accounts;
  • filing income, inheritance and estate taxes;
  • paying all payroll taxes due;
  • paying all debts;
  • distributing remaining assets in accordance with the will or intestate law.

An executor must be informed of the kinds of actions that are considered to be unacceptable.

Here are a few things that the executor should refrain from doing:

  • Distributing assets too soon — as an executor, you should not distribute any assets until there is an accounting of assets and possible liabilities.
  • Using estate assets for personal gain — if you use the assets for personal reasons, you will have to return the funds to the estate, and may face criminal charges.
  • Neglecting to pay taxes — make certain that all taxes are paid.
  • Disregarding court orders — you must obey the judge’s orders.
  • Distributing assets prior to paying bills — you must pay all liabilities prior to distributing assets to the heirs.
  • Disregarding claims against the estate — do not ignore creditors unless a court instructs you to do so.
  • Carrying out your responsibilities without consulting an attorney — Consulting an attorney is an effective way of making certain that you correctly fulfill your duties and do not make any errors.

By adhering to these rules, you can properly carry out the responsibilities associated with being an executor.

Posted on Thursday, July 14th, 2016. Filed under Senior Law News.
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Ask Kit Kat: Pet advice and wisdom as Kit Kat sees it.