Understanding Insurance and Benefits When You Have ALS

Navigating the maze of health insurance is challenging for anyone and can be particularly overwhelming for people with ALS.  We’ve compiled some tips and information that may help save you time and energy spent figuring out the complicated web of insurance benefits.

Questions to Ask Your Health Insurance Provider

A diagnosis of ALS can certainly be overwhelming and many ask, “where do I begin?” What will I need? What does my insurance cover? Below is a list of questions you should ask your insurer:

  • Is there an annual deductible?
  • Is there an annual out-of-pocket expense limit or maximum? If I meet my limit, does my coverage increase and to what extent?
  • Do I have a major medical plan? Is there an annual or lifetime maximum?
  • Do I need to complete any claim forms?
  • Am I subject to pre-existing condition regulations?
  • What does insurance cover/not cover for a person with ALS?
  • Does my plan cover durable medical equipment?
  • Does my plan cover prescription drugs?
  • Does my plan cover home health coverage? Is there a preferred home healthcare agency I must use?

Social Security Disability Insurance (SSDI)

When you are diagnosed with ALS, making a decision to stop working and apply for SSDI may be difficult, but the process for applying for it and Medicare should be relatively easy.  You can file for benefits once you are no longer able to work, or if your current Substantial Gainful Activity (SGA) is below the allotted amount.  The easiest way to file for SSDI is to do so online at http://socialsecurity.gov.  You will need the names and addresses of your doctors, as well as a very brief outline of the work you have done in the last 15 years.  If you are unable to apply online, you can call the Social Security Administration at 1-800-722-1213 or you can apply in person at your local social security office.  Because ALS is on the Social Security Administration’s list of Compassionate Allowances, Social Security will grant you disability status immediately once an application is filed.  There is a full five-month waiting period, so even though Social Security will award disability status immediately, no monetary benefits are paid until after there has been no work for five full months.  Once you are approved for benefits and the full five month waiting period has passed, you will receive monthly monetary payments for you, and in most cases, your minor children and a spouse who cares for your children under age 16.  Your Social Security statement and an on-line benefits estimator can be obtained at http://ssa.gov/myaccount.

Supplemental Security Income (SSI)

Supplemental Security Income provides cash to meet basic needs for food, clothing and shelter to those age 65 and older, blind, or disable who have little or no income.  Individuals and their children may be eligible for SSI even if they have never worked or have an insufficient insured status for SSDI.  SSI is a Federal income supplement program funded by general tax revenues, not Social Security taxes.  Each individual who applies for SSDI is also screened for SSI benefits.  SSI payments may be available during the usual 5-month waiting period before SSDI cash benefits begin. Those eligible for SSI may be automatically eligible for Medicaid benefits.

Medicare and Medicaid

Medicare is a federal health insurance program administered by the Centers for Medicare and Medicaid Services (CMS).  Medicare is available to persons of age 65 and older (and their spouses) and persons eligible for SSDI.  Medicare Part A (hospital insurance) helps pay for care in hospitals as an inpatient, skilled nursing facilities, hospice care, and some home healthcare. This coverage is free to SSDI recipients.  Part B (medical insurance) helps pay for doctors’ services, outpatient hospital care, and some other medical services that Part A does not cover, such as physical and occupational therapy, and some home healthcare. Part B helps pay for these services and supplies when they are medically necessary.  There is a monthly premium for this coverage.  If an individual is also a Medicaid recipient, their monthly premium for Medicare may be paid by their Medicaid benefits.  Please refer to the official Medicare website for the most up-to-date information at http://medicare.gov/Coverage/Home.asp or call 1-800-MEDICARE.  Medicaid provides health coverage for low-income people, families and children, pregnant women, the elderly and people with disabilities.  Federal and state governments jointly fund Medicaid.  For more information on Medicaid contact your state’s Medicaid program.   If you live in Missouri visit https://mydds.mo.gov and if you live in Illinois visit http://illinois.gov/hfs.

For a person with ALS, the most important part of healthcare planning is selecting the best health insurance for their needs.  Discussing health options with an insurance counselor is a great way to think through and plan for your needs to find the most appropriate coverage when you need it.  Your State Health Insurance Counseling Program has expert volunteers who can assist you free of charge.  Go to https://www.medicare.gov/contacts/#resources/ships for more information and as always you can contact The ALS Association St. Louis Regional Chapter through our website or by calling us at 314-432-7257.

The information from this blog post was excerpted from Living with ALS Resource Guide 5: Understanding Insurance and Benefits When You Have ALS.

 

Diagnosing ALS

ALS is very difficult to diagnose — often taking up to a year from when the first symptoms appear until a definitive diagnosis is reached.  Why is diagnosing a person with ALS such a challenging and long process?  Here are a few reasons that can contribute to the delay:

1. There is no clear cause of ALS.

Because there is no clear cause or trigger for ALS, and in most cases, no specific genes, it is diagnosed by asking disease-related questions and taking a history of the patient’s symptoms.  It is very important that a doctor with knowledge of ALS — such as a neurologist or a specialist with experience with ALS — conducts this examination to see the symptoms and clues that need to be observed together to confirm the diagnosis, as well as to rule out other possible conditions.

2. ALS is usually thought of as something else at first.

People with ALS experience a wide variety of symptoms, especially early on in the progression of the disease.  One person may experience muscle twitches or weakness and think at first that they just overexerted themselves at the gym, and another may experience slurred speech and think they may have had a stroke.  The way symptoms present can lead to many areas or specialists before being referred to a neurologist. It’s  typically only when more symptoms appear that ALS is thought of as a possibility.

3. There is no specific diagnostic test for ALS.

An ALS diagnosis is a process of exclusion, which means that doctors have to test for other possible explanations to rule out other diagnoses.  A comprehensive diagnostic workup includes most, if not all, of these procedures:

  • blood and urine studies
  • x-rays, including MRI
  • electrodiagnostic tests including electomyography (EMG) and nerve conduction velocity (NCV)
  • spinal tap
  • muscle and/or nerve biopsy
  • myelogram of cervical spine

When physical and laboratory examinations indicate that a person has weakness caused by the loss of motor neurons, worsening over time and spreading to different parts of the body, along with test results showing a decrease in muscle and nerve function, a diagnosis can be confirmed.  It is always important to get a second opinion, especially when given an ALS diagnosis, because of the wide variety of symptoms and different tests that can be done.

For more information on diagnosing ALS, please see the ALS Association St. Louis Regional Chapter’s website.

Currently, promising research is being done to diagnose ALS earlier and faster with the help of biomarkers. Biomarkers are biological measures that help identify the presence or rate of progression of a disease or the effectiveness of a therapeutic intervention.  Biomarkers can be molecules derived from bodily fluids (blood and cerebrospinal fluid), an image of the brain or spinal cord, or a measure of the ability of a nerve or muscle to process electrical signals.  This research could identify a test that could be done to find an ALS diagnosis earlier in someone’s disease progression, enabling them to start drugs and therapy faster. 

For more information on biomarker research, see The ALS Association’s Research page.

 

Caregiver Confidential: “Who Lives, Who Dies, Who Tells Your Story?”

But when you’re gone, who remembers your name?

Who keeps your flame?

Hamilton, “Who Lives, Who Dies, Who Tells Your Story?”

I was fortunate to see Hamilton in Chicago in December. (I highly recommend going when it comes to St. Louis this spring.) One of the most moving musical numbers and a personal favorite of mine was the finale, “Who Lives, Who Dies, Who Tells Your Story?” In fact, I become teary-eyed every time I listen to the lyrics, because they are so on-point. I thought I finished telling my family’s journey with ALS, but after watching Hamilton, I realized that I had one final point to make.

In earlier posts, I related how my husband Brian learned that he had ALS and our family’s 5-year journey with the disease. What I failed to adequately convey, however, was that your loved one’s legacy should not be defined by ALS. It is easy for this to happen, because of the dramatic and heart-wrenching nature of the illness, and because for many of us, ALS leaves a searing and indelible memory. One must always remember that ALS is what your loved one unfortunately had and does not reflect or represent who he or she was. With that backdrop, I hope you will indulge me in telling you just a little more about Brian, unrelated to ALS:

I first met Brian in October 1967 on the last day of a high school youth group convention. I was from Joliet, and Brian was from Elgin, Illinois. A childhood friend originally from Joliet but living in Elgin said she knew this really cute, shy guy and wanted to introduce us. Brian and his best friend walked into the gym on the last day of the convention, and my friend Barb introduced us. Our conversation lasted only an hour or two before I boarded the bus to return to Joliet, but we clicked immediately. When I got home, I called my best friend and told her that I met the guy I was going to marry. It took almost 7 years for that to happen, but Brian and I were married on June 2, 1974. We were married for 36 years.

Brian and Idelle
Brian and Idelle, December 1970

Who was Brian? Brian loved sports and was a defensive lineman on his high school football team. His favorite baseball team was always the NY Yankees (Brian was born on Staten Island, NY), and he followed Ohio State football from his days growing up in Painesville, Ohio. His favorite college basketball team was the Kentucky Wildcats, which is the one sports team he followed religiously throughout his life. Brian shared his passion for the Wildcats first with his dad, who was a Kentucky alum, and later with our daughter Leah. His adopted St. Louis teams were the Cardinals and Rams, of which he enjoyed attending the occasional game.

Brian loved food, reading, music, travel (we took many wonderful vacations), and gardening, which he found relaxing and meditative. Every morning before work during the growing season, Brian would go outside to contemplate the plants in our front garden bed. Brian always loved nature and the outdoors. Growing up, Brian’s parents thought he would become a forest ranger, but instead he received bachelor’s degrees in environmental science and zoology.

Brian was a very thoughtful, introspective, and intellectual person. He was an extremely hard-working and meticulous medical malpractice defense attorney, who was dedicated to his clients. Brian was a good listener and nonjudgmental person, who cared deeply about people. Above all, Brian was a devoted father and husband to me and our daughter Leah.

This is my last post on our family’s experience (I promise!), and I will be blogging about other caregiving topics going forward. As a survivor, I feel it is incumbent on each of us to give voice to the voiceless, to tell our loved one’s story, and to keep the flame alive. I invite you to share your stories or experiences, anything you feel comfortable relating, in the comments section. Let’s continue the conversation.
Idelle thumbnail

Idelle Winer was primary caregiver to her husband Brian, who passed away in 2010 after a 5-year battle with ALS. A retired medical publishing professional, Idelle offers her unique perspective on a variety of caregiving topics in our feature Caregiver Confidential.

A Day in the Life at the ALS Clinic – The Berkley Family

Last week, our national organization featured our friend, Carmen Berkley, on their blog. Carmen shared her morning attending the ALS Certified Center of Excellence at Saint Louis University — the only one in our region. We’d like to share it here with you.

The Official Blog of The ALS Association

Your life can change in an instant. Carmen Berkley’s life did in 2015. She is one of the 6,000 people diagnosed with ALS each year. In the video below, Carmen shares with us what a visit to an ALS clinic is like for someone living with the disease.

Before diagnosis, Carmen kept busy as a unit secretary on the oncology floor at Barnes-Jewish Hospital in St. Louis and took care of her elderly father. Now, her husband Charles and two daughters, Jamia and Camille, take care of her.

View original post 278 more words

Resources for Caregivers

During National Family Caregivers Month, we recognize and thank the everyday heroes who devote their time and energy to taking care of a loved one.  Millions of people around the country take on the role of caregiver for friends and family members; providing care day and night, on the weekends and even on demand.  Many people, especially those that need long-term care, rely on family and friends as their only source of help.  While many take this on out of love and receive satisfaction from caregiving, it can take a toll over time and even cause detrimental effects to the caregiver’s health and well-being.  It is important for caregivers to make sure they are taking care of themselves, even as they are taking care of others.  Below we have compiled a list of resources to help those in our community navigate the world of caregiving:

Websites

ALS Association St. Louis Regional Chapter

ALS/MND Support Group Forums

ALS Association Support Community- Inspire

Voyce

National Alliance for Caregiving

Family Caregiver Alliance

Caregiver Action Network

AARP

Books

Caregiving: The Spiritual Journey of Love, Loss and Renewal by Beth Witrogen McLeod

Put Your Mask On First: The Caregiver’s Guide to Self-Care by Dr. Gary Bradt and Scott Silknitter

Share the Care: How to Organize a Group to Care for Someone Who is Seriously Ill by Cappy Capossela and Sheila Warnock

Transcending Loss by Ashley Davis Bush

 

Wisdom from Morrie

Morrie Schwartz, a professor emeritus of sociology at Brandeis University, was diagnosed with ALS in the summer of 1994 and passed away in November 1995. He devoted the last year of his life to using his illness to teach others about living and dying. He was an inspiration to friends, students and colleagues—young and old—on dying with dignity. He wrote 75 aphorisms that he called “Reflections on Maintaining One’s Composure While Living With a Fatal Illness”. These aphorisms are the basis of his book,  Letting Go (later republished as Morrie: In His Own Words).

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  • Be clear about what you need and want
  • Ask for it
  • Persist in trying to get it
  • If you don’t get it, know when to give up trying and accept the loss
  • Know you can experience more freedom to be who you really are and want to be because you now have nothing to lose
  • Learn how to combine detachment with involvement, caring with disease, despair with hope, and life with death
  • Let others’ affection, love, concern, interest, admiration, and respect be enough to keep you composed
  • Be patient with and accept your and others’ shortcomings and limitations— again and again and again
  • When you are utterly frustrated and angry, don’t be afraid to express anger or to curse silently, under your breath or out loud if the situation permits. You don’t have to be nice all the time and get people to like you and want to be with you—just most of the time
  • If you need to rail against your fate, do so while you also try to use your situation to enhance and transcend yourself and achieve a higher level of functioning, whatever that may be
  • If you can’t have large victories or achievements, be grateful and celebrate the small ones. Many small ones may add up to a large one
  • Watch for and enhance that which motivates you to be composed and involved
  • Reduce your fear of death
  • Keep your heart open for as long as you can, as wide as you can, for others and especially for yourself. Be generous, decent, and welcoming
  • Be kind and loving to yourself. Befriend yourself. Be compassionate to yourself. Be gentle towards yourself. Do not put others down or criticize yourself continuously
  • Friends and family may see you as less incapacitated than you are because they want you to be “better”. They have this need because they care about you. Accept this, while trying to convey your reality without imposing it on them
  • Whenever a lessening of a physical power occurs, it will always feel to soon. Expect this reaction, and perhaps by preparing for it mentally, you can soften its impact
  • Resist the temptation to think of yourself as useless. It will only lead to depression. Find your own ways of being and feeling useful
  • At some point, be prepared to deal with profound contradictory feeling—for example, wanting to live and wanting to die, loving others and hating them
  • Watch out for emotional, spiritual, or behavioral regression when you are tired, sleepless, or anxious. Try to find ways to avoid that state or get yourself out of it
  • Be aware that you are living in the shadow of increasing dysfunction, discomfort, dependency, and death. Come to terms with this shadow in whatever way you can
  • Allow yourself to be admired— to be an inspiration to others for your behavior, attitudes, and spirit
  • Find a time of the day to face fully your dread, horror, anxiety, fear, rage, and anguish in regard to past, current, and future losses and dysfunctions. Weep and grieve deeply at this time. Once you have honored these feelings, be done with them and go back to your involving life. You may find that you are strengthened by your tears
  • Maintain necessary illusions, but not completely unrealistic ones. For example, to hope that my ALS will reach a plateau or move slowly is realistic, but to expect to be cured is not. Be hopeful, but not too foolishly hopeful

Want some “more-rie”? The New Jewish Theater is starting its 2017-2018 season with a production of “Tuesdays with Morrie”, which has been adapted from Mitch Albom’s best-selling book about his relationship with his professor and mentor, Morrie Schwartz, at the end of his life.  If you’re interested, you can buy tickets here or by calling 314-442-3283.

Tuesdays with Morrie FB Post

Living with ALS: Staying active and staying safe

 

By Elissa Held Bradford, PT, PhD, NCS & Julia Henderson-Kalb, MS OTR/L

Staying active and staying safe are important goals to individuals and families living with an ALS diagnosis. As a person living with ALS you may wish to maintain your independence and participate in activities meaningful to you. This may be taking a trip, going to the park with your grand-kids or being able to go to the bathroom on your own. As a family member, you want to support your loved one’s independence but also his/her safety. As physical and occupational therapists, this goal is our priority too. A common challenge to achieving this goal is falls and concern about falling. This is often complicated by the fact that we may have different perspectives on what constitutes fall risk and independence. However, we can find a happy medium by communicating, planning, and making decisions together. In this short blog post we will discuss falls, fall risk, strategies to prevent falls, fall recovery, risk tolerance and even sense of self to help you stay active and stay safe.

Falls and fall risk

Falls are defined as an unexpected contact with any lower surface. Falls are common in ALS and may result in both minor and serious injury to both the physical and mental self. Physically, fall related deaths associated with head trauma in ALS have been reported at 1.7%.[1] Mentally, falls can decrease your self-confidence and cause you do curtail your daily activities because of concern of falling. Risk of falling in those with ALS has been reported for those who take longer (>14 seconds) to stand up from a chair and walk 3 meters (about 10 ft.) demonstrating weakness in the legs and impaired balance [2]. If you or your loved one has have fallen in the past 6 months, here are some strategies to consider implementing to stay active and stay safe.

Strategies to prevent falls

The Center for Disease Control and Prevention (CDC) recommends 4 key strategies to preventing falls and fall related injuries (https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html, Accessed 5.18.2017).

  1. Talk to your doctor

Talking to your doctor about your falls is important. They can help determine if there are other risk factors besides ALS that may be contributing to your falls, such as medications you may be taking. They can also refer you to see a physical or occupational therapist who can help develop an individualized plan to help you prevent falls. This is important because often your needs are different than others at risk for falls because of the progressive nature of ALS.

  1. Do strength and balance exercises

While strength and balance exercises may not be right for everyone with ALS depending on your fatigue and ability level, evidence in ALS shows moderate-intensity exercise is beneficial [3]. In the healthy older adult, strong evidence supports the role of exercise in fall prevention [4]. In ALS, proper exercise has a role to help you maintain your strength and be more effective in using the strength you do have.

  1. Have your eyes checked

Poor vision can impair your ability to detect and avoid obstacles. While vision loss is not a symptom of ALS, you may have impaired vision for other reasons. Make sure your eyeglass prescription is current.

  1. Make your home safer

This is important in ALS. Make sure your home is free of clutter, including the removal of throw rugs and pieces of furniture that might cause you to trip. Lighting should be bright enough to see your surroundings but not so bright that it impairs your vision. Items used frequently should be within reach. Rails on your steps or a ramp can make it easier to safely enter your home. Outside of the house, consider the environment: are there cracks in the sidewalk or roots/holes in the yard that could create a tripping hazard? Addressing these areas might be necessary.

These CDC strategies are important but for a person living with ALS there are few other key considerations.

  1. Be aware of your environment and yourself

Being aware and mindful of your movements and surroundings is key to making the right choice in the moment to stay active and stay safe. If you are feeling weak, take a rest, and avoid the rocky path.

  1. Trial use of equipment that helps you move

While using equipment can feel like giving in to ALS, it can also be liberating. Find the right fit of enough support when you need it to help balance and save energy, while at the same time building more activity into your day. We often say, ‘We care less if you walk there or roll there, we care more that you get there.’ Don’t let pride or uncertainty stop you from doing the things that bring your life meaning and joy. Equipment such as a walker or wheelchair can keep your world large.

  1. Know what to do in case you fall – fall recovery

Practice getting off the floor with the use of a chair or person to help you, putting your strong leg up first (http://www.webmd.com/healthy-aging/tc/how-to-get-up-safely-after-a-fall-topic-overview#2 ) Remember to check for injuries and ensure it is safe to get up after a fall. If you and your loved one struggle with rising from the floor, call for help from your local fire department or get a lift (Hoyer lift) that can help raise you from the floor.

 Risk tolerance

As we stated in the beginning, we may have different views on fall risk and independence. This is part of our risk tolerance. Risk tolerance is associated with perceived control. Initially if you live with ALS your risk tolerance may be higher because you have greater control on the day to day decisions impacting risk and you experience a greater impact by modifying how or if you do an activity. This can change as mobility becomes more limited and you may rely more on others to help you move. Family members and healthcare providers often have lower risk tolerance because they have less direct control, less direct impact, and may have seen more fall related injuries.  Remember to consider the other perspective and talk out the pros and cons of each decision to maximize both staying active and staying safe.

 Self-identification/Sense of self

Finally, who are you really and what matters most? What is often expressed to us by individuals living with ALS is how hard the loss is – not just physically but psychologically. One of those ways is how the loss of physical abilities in ALS may rob you of the very roles and activities that you use to define yourself as a person – your role as a caretaker or provider for instance, the one who cleaned the gutters, the one who took care of everyone else – your purpose in life. Part of what is hard about making decisions to stay active and stay safe is often a re-examination of your sense of self [5] and purpose. This goes deeper than most conversations about fall prevention but it can be an important one. We encourage you to have these reflections and conversations with yourself and your loved ones. Don’t shy from reaching out to a counselor or your spiritual leader if you are struggling. Your mental self is just as important as your physical self.

Staying active and staying safe is possible in ALS. By knowing your risk for falls, what you can do to reduce your risk, how others may perceive your risk and decisions and finally what is important to you, you and your family can make an informed choice each day that is right for you. Live your life with intent in the ways that matter most to you.

If you want more resources for physical or psychological help, please talk to your healthcare team or visit http://www.alsa-stl.org.

Elissa Held Bradford, and Julia Henderson-Kalb are part of the multidisciplinary care team at the ALS Certified Center of Excellence at Saint Louis University Hospital.


References

[1] Gil J, Funalot B, Verschueren A, Danel-Brunaud V, Camu W, Vandenberghe N, Desnuelle C, Guy N, Camdessanche JP, Cintas P and others. Causes of death amongst French patients with amyotrophic lateral sclerosis: a prospective study. Eur J Neurol 2008;15:1245-51.

[2] Montes J, Cheng B, Diamond B, Doorish C, Mitsumoto H, Gordon PH. The Timed Up and Go test: predicting falls in ALS. Amyotroph Lateral Scler 2007;8:292-5.

[3] Lui AJ, Byl NN. A systematic review of the effect of moderate intensity exercise on function and disease progression in amyotrophic lateral sclerosis. Journal of neurologic physical therapy : JNPT 2009;33:68-87.

[4] Gillespie L, Handoll H. Prevention of falls and fall-related injuries in older people. Inj Prev 2009;15:354-5.

[5] Charmaz K. The self as habit: The reconstruction of self in chronic illness. The Occupational Therapy Journal of Research 2002;22:315-415.