Understanding Long Term Care
WHAT IS MEDICARE?
Medicare is health insurance for
• People over 65 years of age
• People under 65 with disabilities
• People of any age with end stage renal disease
Different Parts of Medicare
Medicare Part A¬–Hospital Insurance
• Helps cover inpatient care in hospitals
• Helps cover skilled nursing, hospice and home health
Medicare Part B—Medical Insurance
• Helps cover doctors’ and other health providers’ services, durable medical equipment and some home health care
Helps cover some preventative services to maintain your health and keep certain illnesses from getting worse
Medicare C—Also known as Medicare Advantage or Medicare Replacement Plans
• Offers health plan options run by Medicare-approved private insurance companies
• Medicare Advantage plans replace traditional Medicare A
Medicare D—Prescription Drug Coverage
• Helps cover the cost of prescription drugs
• May help lower your prescription drug costs
• Administered by Medicare-approved private insurance companies
What does Medicare cover in skilled nursing facilities?
Up to 100 days per benefit period
Days 1-20 Medicare pays 100% of allowable charges. This includes room and board, nursing services, therapies, pharmacy and supplies.
Days 21-100 there is a per-day deductible.
• Benefits will only be paid if skilled services are being provided and with an order from a physician. Examples of skilled services are physical, occupational and speech therapy. It is also certain types of nursing care, such as treatment of wounds.
WHAT IS MEDICAID?
Medicaid is a joint federal/state program that provides health care and nursing home coverage to low income, low asset people. Medicaid regulations are developed at the federal level and implemented at the state level. Medicaid recipients must be United States citizens or legal permanent residents.
Who qualifies for Medicaid?
Medicaid is for people who have low incomes/assets. People who qualify are typically low income adults, their minor children and people with certain disabilities. In most cases, to qualify, a single individual cannot have more than $2000 in assets
What will Medicaid pay for in the nursing home?
Room and board
Transportation to medical appointments
What will nursing home care cost me?
The cost for nursing home care for people
on Medicaid varies by person. A Medicaid case worker will be able to tell you exactly what your cost will be. Typically, you would pay the nursing home your income, minus any allowable expenses. Examples of allowable expenses are:
Personal funds allowance
Medical insurance premiums
Qualifying life insurance plans
Qualifying medical expenses
Qualifying expenses for a spouse at home
The State of Kansas has contracted with private insurance companies to manage the Medicaid program. This program is known as KanCare. Currently there are three managed care organizations (MCOs), Amerigroup; United Health; Sunflower State Health Plan.
Since benefits vary, it is extremely important you understand the differences before you choose a plan.
WHAT IS INDEPENDENT LIVING?
Independent senior living communities, also known as retirement communities, senior living communities or independent retirement communities, are residential housing designed for seniors 55 and older.
Independent senior living communities commonly provide apartments but some also offer cottages, condominiums, and single-family homes. Residents are seniors who do not require assistance with daily activities or 24/7 skilled nursing but may benefit from convenient services, senior-friendly surroundings, and increased social opportunities that independent senior living communities offer.
Many retirement communities offer dining services, basic housekeeping and laundry services, transportation to appointments and errands, activities, social programs, and access to exercise equipment. Some also offer emergency alert systems and on-site beauty and barber salons.
WHAT IS ASSISTED LIVING?
An assisted living resident is defined as a resident who needs assistance with at least one of the activities of daily living, such as eating, dressing, grooming, medication assistance or bathing. A typical assisted living facility resident would usually be a senior citizen who does not need the level of care offered by a nursing home but prefers more companionship and needs some assistance in day-to-day living. Age groups will vary with every community. Many assisted living communities now accept individuals who need assistance with all activities of daily living.
WHAT IS SKILLED NURSING?
A nursing home, skilled nursing facility (SNF), care home, or rest home provides a higher level of residential care. They are a place of residence for people who require continual nursing care and need significant help with activities of daily living. Nursing aides and licensed nurses are available 24 hours a day. Residents include the elderly and younger adults with physical or mental disabilities. Residents in a skilled nursing facility may also receive physical, occupational, and other rehabilitative therapies following an accident or illness. Some nursing homes assist people with special needs, such as people with Alzheimer’s disease.
A skilled nursing facility (SNF) is a nursing home certified to participate in and be reimbursed by Medicare. States have a contract with Medicare to monitor those nursing homes that want to be eligible to provide care to Medicare and Medicaid beneficiaries. Congress established minimum requirements for nursing homes that want to provide services under Medicare and Medicaid. These requirements are broadly outlined in the Social Security Act, which also entrusts the Secretary of Health and Human Services with the responsibility of monitoring and enforcing these requirements. The Centers for Medicare and Medicaid Services is also charged with the responsibility of working out the details of the law and how it will be implemented.
WHAT IS HOME HEALTH CARE?
Home health care refers to care given to a person in their own home. Home health care aims to make it possible for people to remain at home rather than use a nursing home, or assisted living. These services may include some combination of professional health care services and life assistance services. Home health services could include a medical assessment, medication teaching, pain management, disease education and management, physical therapy, speech therapy, or occupational therapy. It could also include daily tasks such as meal preparation, medication reminders, laundry, light housekeeping, errands, shopping, transportation, and companionship. Home Health Care does not typically provide 24-hour care so people need to be sure they have adequate assistance when home health is not providing on-site services.
WHAT IS HOSPICE?
Hospice care focuses on bringing comfort, self-respect, and tranquility to people in the final years of life. Patients’ symptoms and pain are controlled, goals of care are discussed and emotional needs are supported. Hospice believes that the end of life is not a medical experience, it is a human experience that benefits from expert medical and holistic support that hospice offers. Hospice care also involves assistance for patients’ families to help them cope with end of life issues.
Hospice services are usually available at a person’s home, in a retirement center or in a skilled nursing facility.
WHAT ARE MEDICARE SUPPLEMENT PLANS?
A Medicare supplement plan is used to provide coverage for gaps in benefits under Medicare Parts A and B. Also referred to as Medigap plans, a supplement plan is provided by a private health insurance company; however, all supplemental plans must adhere to Medicare regulations that specify 12 different standardized Medigap plans that private insurers can offer. Although all insurers must provide the same coverage under each type of plan, the cost of the plans can differ.
Medicare supplement plans do not cover gaps in coverage for persons choosing coverage with Medicare Advantage Plans.
WHAT ARE MEDICARE ADVANTAGE PLANS?
An Advantage Plan is a contract that Medicare has with a private insurance company to administer your Medicare benefits. It does not pay after Medicare, it pays INSTEAD of Medicare. The premiums associated with Advantage Plans may save you money in the short term; however, when you go see a doctor or go to the hospital, you may have co-payments. There are different types of Advantage Plans. There are HMOs, PPOs and PFFS (Private Fee for Service) plans. With HMO/PPO plans you may be restricted to “in network” doctors, and will need to get “referrals” to go see a specialist. With a PFFS plan, you can see any doctor or hospital that takes Medicare, as long as they agree to accept Medicare payments.
Advantage plans are mandated to cover what Medicare covers. However, not every doctor or hospital that accepts Medicare will accept an Advantage Plan. If you go to a doctor or hospital that does not accept your plan, you may be responsible for the entire bill. Medicare may not pay anything.
The best idea would be to meet with a professional who specializes in these products, and see which plan would be best for your own circumstances.
WHAT IS HOME AND COMMUNITY BASED SERVICES?
A Home and Community Based Services (HCBS) waiver is an authorization from Medicaid that allows a beneficiary to receive treatment at home or in a community setting, rather than being required to enter a nursing home. The HCBS waiver program was initiated in the 1980s. Individual states administer their own waiver programs and have specific information on how to apply for their programs. Social workers and counselors can assist people with the process.
WHAT IS AN ADVANCE HEALTH CARE DIRECTIVE
An advanced health care directive, also known as living will, personal directive, advance directive, or advance decision, is a set of written instructions that a person gives that specify what actions should be taken for their health, if they are no longer able to make decisions due to illness or incapacity.
What is A Living Will
A living will usually provides specific directives about the course of treatment that is to be followed by health care providers and caregivers. In some cases a living will may forbid the use of various kinds of medical treatment. It may also be used to express wishes about the use or foregoing of food and water, if supplied via tubes or other medical devices. The living will is used only if the individual has become unable to give informed consent or refusal due to incapacity. A living will can be very specific or very general. An example of a statement sometimes found in a living will is: “If I suffer an incurable, irreversible illness, disease, or condition and my attending physician determines that my condition is terminal, I direct that life-sustaining measures that would serve only to prolong my dying be withheld or discontinued.”
WHAT IS POWER OF ATTORNEY
Power of attorney is granted to an “attorney-in-fact” or “agent” to give that individual the legal authority to make decisions for an incapacitated “principal.” The laws for creating a power of attorney vary from state to state, but there are certain general guidelines to follow. Before you or a loved one signs any documents, however, be sure to consult with an attorney concerning all applicable laws and regulations.
The principal determines the amount of power given to the attorney-in-fact, and this individual can be given the authority to deal with only one particular issue (a specific power of attorney), or to handle most of the principal’s personal and financial matters (a general power of attorney). Regardless of the type of power of attorney granted, the attorney-in-fact is responsible for keeping accurate records of all transactions that he or she makes on behalf of the principal. The attorney-in-fact also is responsible for distinguishing between the types of decisions he or she has the power to make and other decisions.
There are multiple types of decisions that the attorney-in-fact can be given the power to make, including the power to:
• Make financial decisions
• Make gifts of money
• Make health care decisions, including the ability to consent to giving, withholding, or stopping medical treatments, services, or diagnostic procedures. (Note: your loved one can also make a separate “health care power of attorney” to give only this power to an individual.)
• Recommend a guardian
WHAT IS DURABLE POWER OF ATTORNEY
A durable power of attorney is a legal document that enables an individual to designate another person, called the attorney-in-fact, to act on his/her behalf, even in the event the individual becomes disabled or incapacitated. An “advance directive” (sometimes called a “health care directive”) combines a living will and durable power of attorney, either in one document or two separate ones.
WHAT IS DO NOT RESUSCITATE
In medicine, a “do not resuscitate” or “DNR”, sometimes called a “No Code”, is a legal order written either in the hospital or on a legal form to respect the wishes of a patient not to undergo CPR or advanced cardiac life support (ACLS) if their heart were to stop or they were to stop breathing. The term “code” is commonly used by medical professionals as jargon for “calling in a Code Blue” to alert a hospital’s resuscitation team. The DNR request is usually made by the patient or health care power of attorney and allows the medical teams taking care of them to respect their wishes. In the health care community “allow natural death” or “AND” is a term that is quickly gaining favor as it focuses on what is being done, not what is being avoided.