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Understanding Medicare Coverage For Nursing Care

Episode 13 of the Coach’s Corner Podcast is entitled Understanding Medicare Coverage For Nursing Care. Grasping Medicare coverage can be tricky, especially when it comes to Part A coverage for nursing care. This episode will focus on clearing up those myths and misconceptions about Medicare Part A with special guest, Nicholle Dixon, Messiah Village Billing Coordinator. Learn more about:

  • Medicare versus Medicaid
  • how Medicare Advantage Plans differ from traditional Medicare
  • what are the qualifications for nursing coverage
  • what is considered skilled nursing care, as opposed to intermediate or custodial care
  • the myth of the 100 day benefit period and details on days 1 to 20 and 21 to 100
  • where to get help with Medicare

Medicare Resources

Statewide APPRISE Medicare Counseling Program Pennsylvania offers a free health insurance counseling program (APPRISE) designed to help older Pennsylvanians with Medicare. Counselors are specially trained staff and volunteers who can answer your questions about Medicare and provide you with objective, easy-to-understand information about Medicare, Medicare Supplemental Insurance, Medicaid, and Long-Term Care Insurance. Click [here] to visit the APPRISE website.

Official United States Government site for Mediacare www.medicare.gov/

Autumn: Pumpkins, Football and…. Medicare Open Enrollment?

 For most, the fall season is synonymous with football, the beauty of autumn and everything and anything pumpkin flavored or scented. However, fall now includes a new seasonal tradition- shopping for the right Medicare plan during open enrollment season, which now runs each year from October 15 through December 7.

Medicare provides health insurance benefits to over 52 million seniors and disabled people in the US¹. And that number continues to balloon as nearly 10,000 baby boomers turn 65 every single day, thus becoming eligible for Medicare. Due to this surge, Medicare is continually changing and must evolve to remain sustainable. The health insurance landscape for seniors really began to change in 2006 with the implementation of the Medicare Part D drug program and proliferation of Medicare Advantage plans. Medicare Advantage plans were created as a more cost-effective type of Medicare health plan offered by private insurance companies that contract with and serve as a substitute for original Medicare, which then provides recipients with their Part A and Part B benefits.

The new normal

Ideally, this new normal was meant to give Medicare recipients more choice and the capability to do cost comparisons between plans that fit individual need and budget. However, the benefit of vast choice actually creates frustration and confusion for many and may cause “decision-making paralysis.” Research has found that because of this, many Medicare recipients just go with last year’s plan because they feel it’s too much effort to switch plans. That decision could come back to haunt them because their plan, that was perfect last year, now may have higher premiums and co-pays or may no longer really meet their specific healthcare needs.

Undoubtedly, this labyrinth of terminology, benefit options, rules, penalties, and a myriad of forms can be staggering, especially if you’re technologically challenged due to much of the research and registration options being online. But again, annual open enrollment is said to encourage Medicare recipients to spend their money more wisely, take better care of themselves, and get better personalized health coverage. It may also be said that our health and welfare should at least be worth this effort once a year. These are all great points, but we must find a happy medium.

Medicare recipients should take more responsibility for their choice of healthcare coverage and should feel fortunate to have these choices. However, the Centers for Medicare & Medicaid Services and private insurers need to streamline the process and make it a little easier, especially for seniors. Congress needs to enact legislation to consolidate Medicare Advantage and Part D plan choices and standardize options in order to facilitate informed decision-making by Medicare plan enrollees.² Granted it is not an easy fix, but MedicareRights.com shares an interesting article,”50 Wishes for Medicare’s Future,” which details a number of ideas and solutions to fix Medicare and its delivery system.

Until then, those eligible for Medicare can find help on sites like
MedicareInteractive.org, which provides a number of resources and tips such as:

  •   If enrollees want to join a stand-alone prescription drug plan (PDP), they can use the Plan Finder tool on Medicare.gov. The Plan Finder tool compares plans based on the drugs you need, the pharmacy you go to and your drug costs. And remember coverage changes every year. The cost of your medications may look very different from the year before.

  •   If enrollees want to join a Medicare Advantage Plan, they can call 1-800-Medicare or go to Medicare.gov to find out what plans are available in their area. Once they receive the list of plans, they can check the plan websites to see which best fits their needs and budget.

  •   Call or visit the website of your State Health Insurance Assistance Program or SHIP. Your state SHIP can help you to understand all of your Medicare coverage options, and counselors are available to meet with enrollees one-on-one, in person at no cost. In Pennsylvania, the APPRISE Program offers SHIP.

Lastly, Messiah Lifeways Coaching will be hosting two separate days (Nov. 1 and Nov. 28, 2017) in which APPRISE counselors will be on hand to offer FREE 1 hour one-on-one counseling sessions. If you live in the Cumberland County area, please schedule an appointment by calling 717.240.6110. Slots are going quickly! For other counties and locations, call the State hotline at 1.800.783.7067 or call your local Area Agency on Aging. 

For additional resources on Medicare, check out the links below:

¹CMS.gov
²medicarerights.org/50wishes/streamline-enrollment
True or False: Long Term Care for Seniors

Long-Term Care: True or False?

From nursing homes to hospice care, or Medicare to power of attorneys, there are many myths and misconceptions about long-term care in Pennsylvania. Often long-term care and its details can be misinterpreted, miscommunicated, may be outdated or, in some cases, difficult to thoroughly understand. As older adults and/or their families begin to navigate the waters of long-term care, the journey can become complicated. With numerous options and decisions to be made, coupled with medical and insurance jargon and the fast pace of healthcare, making the right decision about the care you or a loved one needs is a challenge. This is especially true for those entering this labyrinth for the very first time.

Below is a sampling of a few common myths and misconceptions people have about long-term care, along with the answers to some of these often asked questions. Some answers may surprise you; others may affirm your knowledge, and some will help you make swifter and more educated choices. It should also help individuals plan ahead and get a better handle on terminology, plus shed light on the cost of care and whether you are financially prepared. Take the test and see how you fare.

TRUE OR FALSE?

1.      Personal care homes and assisted living facilities in Pennsylvania are one in the same. 

2.      Medicare pays for personal care/assisted living in Pennsylvania. 

3.      The monthly median cost of a one-bedroom in an assisted living residence or personal care home in Pennsylvania is $3,555. 

4.      The percentage of those 65+ living in nursing homes at any one point across the U.S. is approximately 15%. 

5.      The percentage of those 65+ that will need some form of long-term care (community based and/or facility based care) is 95%. 

6.      Medicare pays for long-term care in a nursing facility indefinitely. 

7.      The annual median cost of a semi-private (shared) nursing bed in Pennsylvania is $73,753. 

8.      Nursing Homes take all your money up front including your home, even if your spouse is still living there.

9.      The percentage of U.S. retirees with $100,000 or less in savings and investments is 71%.

10.   Hospice care neither prolongs life nor hastens death.

11.   Hospice is not limited to the 6-month terminal illness diagnosis.

12.   A person must be competent to sign a Power of Attorney or Advance Directive/Living Will. 

Answers:

1.      False! In 2011, the Office of Long-Term Living under the PA Department of Human Services began to license Personal Care Homes (PCH) and Assisted Living Residences (ALR) as two separate levels of care in PA. Though similar, there are differences based on concept, construction, and level of care. Currently there are approximately 1,200 licensed personal care homes in Pennsylvania as compared to only 35 licensed assisted living residences.²

2.      False! The only level of domicile/residential care that Medicare Part A covers is nursing care. This coverage is based on medical necessity and most often requires a qualifying stay in an acute care hospital.

3.      True! The average median cost is $3,555, which is an annual median cost of $42,660.¹ Despite their being a difference in licensure; current financial data for the cost of personal care and assisted living are lumped together. In Pennsylvania, these costs are out-of-pocket almost exclusively. 

4.      False! Estimates between 2013-2015 states anywhere from 3.1 to 3.4% of those ages 65+ live in institutional settings such as nursing homes at any one point. 

5.      False! The number currently stands around 70%.² Though most seniors won’t move into a nursing home long-term (see question 4), this statistic shows that a majority will need care and services provided by family and/or professionals both inside or outside the home. 

6.      False, False, False! Medicare Part A covers the cost of skilled nursing care for a limited benefit period. For more details on coverage and benefit periods, please go to Medicare.gov

7.      False! The annual average median cost for a shared nursing accommodation in PA is $105,485.¹ 

8.      False!!! Nursing homes are fee-for-service and charge a daily rate and bill on a monthly basis, much like paying a monthly rental. Therefore there is no upfront payment or entrance fee. Secondly, thanks to the enactment of spousal impoverishment rules, if a spouse or dependent child still lives in the house, the home is protected from having to be liquidated to pay for nursing care. Furthermore, a specific amount of joint assets is protected for the spouse still living in the community. To learn more about spousal impoverishment rules, visit LongTermCare.gov.

9.      True! Very sadly almost ¾ of retirees in the U.S. have less than $100,000 saved for retirement.³ Compare that to the annual median cost of a semi-private nursing room in PA, and you get a sense of how long (or not) your retirement savings might last.

10.   True! Hospice staff and volunteers offer a specialized knowledge of medical care, including pain management. The goal of hospice care is to improve the quality of a patient’s last days by offering comfort and dignity.

11.   True! Hospice services can extend well beyond 6 months as long as their physician certifies the need.

12.   True! In PA, after the Power of Attorney (POA) or an advance directive is drafted, the principal (the person making the POA) must be capable of understanding the document in order to sign it. However, elder law attorneys state that if a person suffering from dementia or Alzheimer’s disease has a “lucid moment” and are competent at the moment, they can still sign these documents and they would remain valid even if they do not remember signing it later on.

Scoring:SHOCKED

12 correct – very impressive!
8-11 correct – good job!
4-7 correct – definite room for improvement
0-3 correct – you better call the Coach for help! >

This list of questions could go on and on, and there is so much to learn. So if you have another question that isn’t on this list, please contact Messiah Lifeways Coaching at 717.591.7225 or email coach@messiahlifeways.org.

¹Genworth Financial Cost of Care Survey 2015
²Pennsylvania HealthCare Association, Long-Term Care Trends and Statistics
³Employee Benefit Research Institute and Greenwald & Associates, 2004-2016 Retirement Confidence Surveys

 

Autumn: A Time for Football, Pumpkins and Medicare?

For most, the fall season is synonymous with football, the beauty of autumn and everything and anything pumpkin flavored or scented. However, fall now includes a new seasonal tradition- shopping for the right Medicare plan during open enrollment season, which runs each year from October 15 through December 7 .

Medicare provides health insurance benefits to over 52 million seniors and disabled people in the US¹. And that number continues to balloon as nearly 10,000 baby boomers turn 65 every single day, thus becoming eligible for Medicare. Due to this surge, Medicare is continually changing and must evolve to remain sustainable. The health insurance landscape for seniors really began to change in 2006 with the implementation of the Medicare Part D drug program and proliferation of Medicare Advantage plans. Medicare Advantage plans are a type of Medicare health plan offered by private insurance companies that contract with and serve as a substitute for original Medicare, which then provides recipients with their Part A and Part B benefits.

The New Normal

This relatively new autumn “tradition” continues to thrust its way into the lives of seniors and the disabled across the US year after year. In a matter of speaking, I’d say some may view open enrollment similarly to that of an annual health physical, “a very unpleasant, but very necessary deed.” Researching and (re)enrolling for a Medicare plan every fall is no fun, but again essential. It’s not changing anytime soon, so I guess enrollees better get used to it. Ideally, this new normal was meant to give Medicare recipients more choice and the capability to do cost comparisons between plans that fit individual need and budget. However, the benefit of vast choice actually creates frustration and confusion for many and may cause“decision-making paralysis.” Research has found that because of this, many Medicare recipients just go with last year’s plan because they feel it’s too much effort to switch plans. That decision could come back to haunt them because their plan, that was perfect last year, now may have higher premiums and co-pays or may no longer really meet their specific health care needs. Undoubtedly, this labyrinth of terminology, benefit options, rules, penalties, and a myriad of forms can be staggering, especially if you’re technologically challenged. But again, annual open enrollment is said to encourage Medicare recipients to spend their money more wisely, take better care of themselves, and get better personalized health coverage. It may also be said that our health and welfare should at least be worth this effort once a year. These are all great points, but we must find a happy medium.

We should take more responsibility for our choice of healthcare coverage and we’re fortunate to have that choice. However, the Centers for Medicare & Medicaid Services (CMS) and private insurers need to streamline the process and make it a little easier, especially for seniors. Congress needs to enact legislation to consolidate Medicare Advantage and Part D plan choices and standardize options in order to facilitate informed decision-making by Medicare plan enrollees.² Though it is not an easy fix, it’s one of a number of solutions out there. In particular, MedicareRights.com shares “50 Wishes for Medicare’s Future,” which details a number of ideas and solutions to fix Medicare and its delivery system.

In the meantime, here are some resources from MedicareInteractive.org to make this process a bit easier to understand and navigate:

  • If you want to join a stand-alone prescription drug plan (PDP), use the Plan Finder tool on Medicare.gov. The Plan Finder tool compares plans based on the drugs you need, the pharmacy you go to and your drug costs. And remember coverage changes every year. The cost of your medications may look very different from the year before.
  • If you want to join a Medicare Advantage plan, call 1-800-Medicare or go to Medicare.gov to find out what plans are in your area. When you receive the list of plans, check the plan websites to see which best fits your needs and budget.
  • Call or visit the website of your State Health Insurance Assistance Program or SHIP. Your state SHIP can help you to understand all of your Medicare coverage options, and counselors are available to meet with enrollees one-on-one at no cost. In Pennsylvania SHIP is referred to as APPRISE, which is available in each county and holds free open enrollment events. Messiah Lifeways will be hosting several of Medicare Part D events in October and November. To get a list of those dates and locations in Cumberland County please click [here] and for a full list of events for every county, please click [here.]

For additional resources on Medicare, check out the links below:

¹CMS.gov
²medicarerights.org/50wishes/streamline-enrollment

 

Non-profit Nursing Homes Offer Certain Advantages

Those that have gone through the process of finding a nursing home for a loved one can tell you how much of a challenge it can sometimes be. Making such an important decision for an ailing parent or loved one can be difficult and overwhelming. Knowing the right questions to ask and the right characteristics to look for are vital to making a better and more informed choice. You can go online (medicare.gov as one example) and print a list that consists of questions like “what’s the staffing ratio?”, “do you do background checks on staff?”, or does it smell and look clean? But one question to ask that you may not always see on these lists is whether it is a non-profit or a for-profit facility. Being aware of the ownership status can be a very good starting point.

A number of national senior and health care advocacy groups like Leading Age, Physicians for a National Health Program and the Center for Medicare Advocacy, Inc have determined through extensive research that the type of nursing home ownership and sponsorship can affect the quality of care that facilities provide to their residents. It can even affect the rate of hospitalization and the potential discharge to home percentage.

Much of the statistical research consistently determined that non-profit nursing homes offered specific advantages, such as:

>fewer deficiencies in total
>fewer deficiencies causing harm or jeopardy to a resident
>fewer residents taking antipsychotic medications
>lower prevalence of restraints
>lower prevalence of pressure ulcers (bed sores)
>lower hospitalization rates
>higher staffing number of registered nurses
>higher staffing ratios overall
>higher ranking on the Center for Medicare/Medicaid (CMS) Five-Star rating system
>higher discharge to home rates

I’m not suggesting that 100% of the time a non-profit nursing home is always a better choice; however, it’s hard to argue with these numerous sources and research supporting the facts. Non-profit retirement communities and nursing homes like Messiah Village are not looking to create profit for shareholders or the executives running the company. If positive revenue exceeds operational costs, non-profits typically put that money back into the facility by making improvements to the physical plant, focusing on staff retention and increasing wages, and by looking for ways to improve policy and procedure to create a better overall living experience for residents.

Ultimately deciding on a nursing home for a parent or spouse needs to be a well-planned collaborative decision, involving the perspective resident and their loved ones and/or their responsible persons. Taking suggestions from the doctor, a social worker or someone who’s gone through it is fine. However, there are more precise ways to evaluate the choice. In Pennsylvania, go to the Department of Health website to obtain a full list of nursing homes county-by-county, which also includes detail about profit vs. non-profit status, licensed number of beds, plus survey results that lists specific deficiencies and the subsequent plan of correction. Also call to schedule visits and tour several nursing facilities. And, if possible, do this ahead of time, not at the last-minute or during the time of crisis.

For more information or questions about finding the right nursing home for you or a loved one, please contact the Messiah Lifeways Coaching office at 717-591-7225 or email coach@messiahlifeways.org.

Resources cited:

“Non-profit nursing homes provide better care, major study finds” from www.PHNP.org

“Non-Profit vs. For-Profit Nursing Homes: Is there a Difference in Care?” from www.medicareadvocay.org

“5 Ways Not-for-Profit Nursing Homes are Different” by Geralyn Magan at www.LeadingAge.org

“For-Profit Nursing Homes Have Low Staffing and Poor Quality of Care” by Grace Rattue at www.medicalnewstoday.com

 

Initially Published- 06/20/2013

 

Finding the Right Place (Part 3- Nursing Care)

So far in this three-part series, we have examined finding the right personal care home [part 1] and assisted living residence [part 2] for a loved one. Now the focus turns to nursing care, which includes skilled or intermediate nursing care, as well as rehabilitation.

Of all three levels to research this may be the most challenging and angst-ridden choice of all. Let’s face it, most people do not want to go to a nursing home, and family members can feel a great deal of guilt and trepidation during this process. At least with personal care or assisted living your parent or spouse is likely healthier and fairly independent and can embrace and even enjoy making a move. But when it comes to the point of needing nursing care, often times you may be making the primary decisions for a loved one who may be too ill or incapable of choosing on their own.

Defining Nursing Care
First, let’s clearly define nursing care. Skilled nursing provides continual daily nursing care and rehabilitation under the supervision of a physician. Examples of skilled care include physical therapy, intravenous injections, and wound care. Medicare A will pay up to a maximum of 100 days per benefit period, as long as there continues to be a skilled need within that period. Otherwise, if custodial care, like assistance with bathing, tolieting, feeding, or medication monitoring, becomes the exclusive need, it is then considered intermediate nursing care, which Medicare does not pay for. Intermediate nursing care is either private pay or covered by privately purchased long-term care insurance or by Medicaid (aka Medical Assistance) for those who qualify. And just like personal care and assisted living, the healthcare professionals involved with their care should be able to recommend whether nursing care is necessary.

A Wild and Emotional Goose Chase
First off, health care has changed and time is typically of the essence, especially when choosing a nursing home. The entire process of picking a nursing home will differ from the other two options for several reasons. First, the pace will be much faster. Most of the time with personal or assisted care, you’re not dealing with an emergency or critical placement. But with nursing, if an injury or illness occurs in the blink of an eye, the ever-shrinking time someone spends in the hospital doesn’t give you much leeway to research and choose a facility before their discharged and deemed unsafe to return home. Another issue is that you may have to negotiate or settle on a choice because of no availability, or certain facilities may not be able to meet your loved one’s needs, and in some cases insurance may influence your options. For instance, does the facility take Medicare or Medicaid? Meanwhile as you’re on this goose chase you’re likely dealing with the physical, emotional and mental complexities that you and your loved one are enduring. This is not meant to send you into a panic, but rather to provide a dose of reality that many families face after a loved one is hospitalized and or is recommended for nursing care.

If you are comfortable using a computer, which I assume you are if you are reading this, then technology can help expedite this process much faster. Just as with choosing a personal care home or assisted living, there are online resources to obtain a clear concise list of nursing homes in your area. The PA Department of Health- Nursing Care Facility Locator link provides a list county by county. It details their contact information, and you can compare the following information: non-profit versus for-profit status, number of beds, payment options, and nursing hours per resident per day. As you peruse this link, please note that the state required nursing hours per resident per day is 2.7 hours. You can also key in on the patient care and building safety inspection surveys. Medicare.gov also offers a nursing facility locater by zip code and displays the national five-star rating-system for nursing homes in your area. You can also visit eldercare.gov or call 1-800-677-1116 for more information on long-term care choices nearby.

As you begin to whittle down those choices based on the information you’ve gathered online, you can start to apply some of the previous principles to narrow the choice even further. Again to streamline the search, be sure to call for availability and ask about admission criteria and financial guidelines. Recommendations from the doctor, clergy or a social worker can at times be helpful. However, remember to ultimately make your own judgment. Next comes the all-important tour. Once you arrive for your scheduled tour, don’t be afraid to ask questions. Now is the time to ask. Also if a resident or a resident’s family allows, talk to them about the care and their experience. Take notice of your surroundings using your eyes, ears and especially your nose. Inquire about amenities on-site for your loved to go to like an activity area, gift shop, restaurant or library. Ask to talk with the activity or enrichment staff, or request an activity calendar and menu. For further questions to ask and a nursing home checklist, go to medicare.gov/NHCompare.

Once you have toured your revised list, submitted an application, and the facility has accepted your loved one and offers a bed, you will then work with their admissions department and the hospital to coordinate the sign-in and the admission itself. Be sure that you have their insurance cards and other important documents like a power of attorney and living will available for copy. And remember, this quite often is a rapidly moving process.

Plan Ahead as Much as You Can
Despite that finding nursing care is the most challenging to plan ahead for and can be a sensitive subject to discuss, be as proactive as you can be. If you recognize that a parent’s or spouse’s health is declining, doing some preliminary research can be a great help. Planning ahead also gives them a bigger role in the decision-making process, which is important in making this difficult transition. It’s also good to have several options, in case the first option has no openings. The hospital won’t let mom hang out until her first choice opens up. However, you do have the right to move her from that nursing facility to her first choice once they have an opening. Lastly, you’ll find that most facilities require an application and typically don’t have an application fee. So, if you really want get a jump on planning, submit an application ahead of time for future need. Hopefully you or your loved may never need to make that move, but if you do, you’re that much ahead of the game.

For more tips and information about choosing the right nursing home for a loved one, please contact the Coach at 717.591.7225 or email coach@messiahlifeways.org.