Instructor: Shelley Bhattacharya, DO, MPH
Reviewed by: Anne Walling, MB, ChB
Specific Learning Objectives
A. Introduction
Before reviewing the learning objectives and content, please take the following Pre-Test. You must do this before you can proceed with the module. The answers are given in the Post-Test that complete the module.
Please review the Objectives, Content material, and Cases before our class session. We will apply the tasks in the Skills Objectives to these cases, and you should think about them ahead of time.
B. Attitudes
The student will develop a sense of responsibility for the individual and societal costs of health care for older adults that incorporates respect for individual rights and quality of life.
C. Knowledge - The student should be able to describe or explain
D. Readings
E. Skills
F. Cases
Medicare is the federal program that provides health insurance to more than 39 million people who are age 65 or older, or who have a disability. The Centers for Medicare and Medicaid Services (CMS), working with numerous local contractors, administers the program. The annual 2008 budget for CMS is over a billion dollars a day. The Medicare program offers beneficiaries in many communities a choice between "Original Medicare," the fee-for-service program that dates to 1965, and Medicare+Choice which includes Medicare's Managed Care and Private Fee for Service options.
Medicare does not pay for the costs of long-term care for chronic conditions, even if that care is provided in a nursing home setting. Nursing home residents pay, on average $50,000 per year to live in a nursing home. When their money runs out, they may apply for government assistance through the state Medicaid program. Medicaid pays for health care for certain categories of very low income/low wealth persons, and ends up paying about half of annual nursing home costs.
In order for Medicare to pay for health-related costs, the services or equipment must be considered to be “medically necessary.” There are other criteria that must be met in order for Medicare to pay.
Home health care cost may be paid by Medicare if the following circumstances are present: the services are declared medically necessary by the physician; the patient needs skilled care:
- skilled nursing
- physical therapy
- speech language pathology
on an intermittent basis; the patient must be home bound; and services are provided by a home health agency approved by the Medicare program. Each of these terms have very specific definitions. If Medicare denies payment for the service, then Medigap will generally deny payment as well.
Medicare will pay toward hospice services under the following conditions:
- the person has Part A Medicare (most, but not all, older adults do!);
- two doctors agree the patient is terminally ill and probably has less than 6 months to live;
- the patient signs a statement choosing hospice care instead of routine Medicare covered benefits for care of the terminal illness;
- services are received from a Medicare-approved hospice program.
If these conditions are met, Medicare will pay for in-home hospice care, free-standing hospice care (if available in the community) and/or hospice services received in a nursing home facility.
Medicare Part A is also known as "Hospital Insurance." Medicare Part A is financed largely through payroll contributions from employers and employees. The covered services in this program include inpatient hospital care, skilled nursing facility care, and some health care. Medicare patients who enter a hospital are charged for a Part A deductible ($1,024 in 2008) for each Benefit Period. As the length of stay during a hospitalization increases beyond 60 days, additional daily premiums are assessed. (See link for Medicare Plan Costs). A Benefit Period starts on the first day a patient enters a hospital as an inpatient, and ends 60 days after the patient leaves the hospital or a skilled nursing facility. This means that a patient could face several Part A deductibles in the course of a year.
Medicare may pay for up to the first 100 days in a nursing home, as long as the patient had spent the immediate 3 days in a hospital, and as long as the patient is receiving skilled medical care.
Fiscal Intermediaries- private insurance companies that contract with CMS- review Part A claims and make coverage decisions based on Medicare guidelines as set forth in various CMS Manuals and Program Directives.
Medicare Part B is also called "Medical Insurance." Part B is financed through federal general revenues and the monthly premiums ($96.40/mo. for individuals with income under $82,000 in 2008) that Medicare beneficiaries pay. The covered services in this program include physician services, outpatient hospital services, home health care, durable medical equipment, medical supplies, ambulance services, prosthetic devices and more. However, items such as eye glasses, dentures, and hearing aids are generally not covered. The Part B program generally pays 80 percent of Medicare's approved amount for covered services, after the patient pays the first $131 in Medicare's approved charges. This Part B deductible operates on an annual basis, unlike Part A with its Benefit Period system. In addition to the annual deductible, Medicare beneficiaries owe a 20 percent coinsurance charge for services covered under Part B. Medicare Carriers-private insurance companies that contract with CMS-review Part B claims and make payment decisions based on Medicare guidelines as set forth in the CMS Carriers Manual and CMS's National Coverage Determinations.
Medicare Part D is a drug coverage benefit for all Medicare beneficiaries. It became effective January 1, 2006. All beneficiaries must sign up for a particular Part D plan to get coverage. Prescription drug coverage is not free, except for those who meet financial criteria. Three major issues that are raised with Part D coverage are 1) How do you enroll, 2) Which medications are covered and 3) How much will it cost?
- Enrollment
Except for Medicaid patients, enrollment is NOT automatic.
All enrollment information can be accessed at www.medicare.gov. Medicare provides a tool for practitioners to practice navigation through the Part D enrollment process. It can be accessed at http://www.medicare.gov/medicarereform/partdprototype.htm Try it!
To be covered from January 1, non-Medicaid patients have until December 31 of the previous year to enroll. Coverage will begin the 1st of the month following enrollment. If a patient chooses to delay enrollment in a Part D plan, there will be a 1% base premium penalty for each month that the patient was eligible but did not enroll. THIS PENALTY IS ONGOING AND IS ONLY WAIVED IF YOU HAVE CURRENT COVERAGE BY ANOTHER PLAN THAT MEETS OR EXCEEDS THE MEDICARE COVERAGE.
The annual open enrollment period is November 15-December 31 of each year. This period can be used for new enrollment or for current members to switch plans. The penalty fee will still be assessed if they did not meet the exclusion criteria highlighted above.
Patients are NOT required to enroll in a Part D plan. If they currently have medication coverage through an employer plan, they need to decide if their current coverage is better than what Medicare is offering.
On January 1, 2006 all Medicaid patients were automatically assigned to a Part D plan if they had not already enrolled in a plan. Other ways to enroll are through 1-800-MEDICARE and through community programs where enrollment is assisted by Medicare trained professionals.
- What is covered?
Part D coverage will cover generic and brand name medications available only by prescription. Medications are available through local or mail order pharmacies. Medications from Canada and non-prescription meds will not be covered.
Each drug plan has its own formulary. It is up to the patient to select the plan that best covers their particular medication regimen. The website, www.medicare.gov, will allow patients to enter their particular medication regimen and the site will subsequently provide a list of plans individualized for that patient’s medication coverage.
- How much will it cost?
Part D payment system is a tiered system. Click here for the Standard 2008 Part D benefit has not changed since 2006.
Each state has a unique set of plans, each with their own premiums and deductibles. All plans can be viewed by patients or practitioners at www.medicare.gov
The average national monthly premium is $32.20. All states, except Alaska, have at least one plan with premiums below $20. Kansas and Missouri each have two plans with premiums below $20. The website will help guide patients with state specific plans.
Extra help is available for those with limited resources. Those that are below 150% of the Federal poverty level save about 95% on average. They will have no premiums or deductibles and small copays. Long term care patients and Medicaid patients will have no premiums, deductibles or copays.
Medicaid is a federal/state program that provides health insurance coverage to special categories of low-income persons, including the low-income elderly. Medicaid pays about 60% of nursing home costs in the U.S.; most people cannot afford to pay the $51,000 average annual costs for nursing home care. Medicaid used to cover medications, however since the introduction of Medicare Part D on 1/1/06, this benefit will no longer be covered as a Medicaid service. All Medicaid beneficiaries will automatically be transferred to a Medicare Part D drug plan for their medication coverage.
These are health insurance policies sold to people who have Medicare coverage. Medigap policies work to help pay part of the expenses that are not completely covered by Medicare. There are various types of Medigap policies. Some pay the Medicare deductibles and co-payments. Some offer coverage for items not covered by Medicare at all. Many, but not all people who receive Medicare have purchased additional Medigap insurance coverage.
Long-term care insurance is yet another type of insurance product marketed to middle age and older people. These policies differ considerably. In general, the concept behind LTC insurance is to pay for nursing home care and/or community-based long term care for chronic health conditions. The Federal Medicare programs pays for less than 5% of nursing home care. Medicaid will pay for nursing home care after a person is declared to have insufficient financial resources. The ability to pay out of pocket, or the availability of LTC insurance, can allow a person to enter a nursing home that may not accept people on Medicaid. The average annual cost for a nursing home stay in the U.S. is $51,000.
What is a Case Manager?
Case managers are health professionals (generally with a background in social work or nursing) who help foster functional independence among clients. They do this by working with clients to identify, assess, articulate, and prioritize their health-related needs, including mental health and social needs. Case managers (sometimes referred to as “Care Managers”) help clients learn about available resources to assist in maximizing their independence.
Case managers work in different settings. The type of setting will determine, in part, the eligibility criteria for becoming a client and the extent of the services available. Case managers may be in private practice. They may be employed by a hospital, HMO, or insurance company. They may be part of a social services organization, or affiliated with a religious organization.
The National Advisory Committee of Long-term Care Case Management defines case management as, “coordinating services that helps frail elders and others with functional impairments and their families identify and secure cost effectively administrated services appropriate to the consumer’s needs” (Connecticut Continuing Care, Inc., 1994, p.5).
There is an emphasis on planning and individualizing services to promote independence. Your office staff can provide you and your patients a valuable service by connecting patients with excellent case management services.
Wacker, R.R., Roberto, K.A., & Piper, L.E. (1998). Community Resources for Older Adults: Programs and Services in an Era of Change. London: Pine Forge Press, page 308, provide this diagram to understand the steps of case management:
Case Management Comprehensive Assessment
According to Wacker et al., (1998 p. 453), when the case manager determines that a client is eligible for case management services, the case manager conducts a multidimensional assessment that profiles details of the client’s needs and support systems. Although the specific assessment tools used vary across programs, the following questions are typical of some of the areas addressed during the assessment process:
- History and nature of illness?
- Medications?
- Client’s perception of health status?
- Client coping skills?
- Does the client have memory problems?
- To what extent can the client dress, eat, bathe, walk and use the toilet without help?
- Who, if anyone, supports the client among family, friends, church and neighbors?
- What physical characteristics of the client’s dwelling help or hinder the client’s mobility?
- What financial resources are available to the client to pay for service
Community Based Geriatric Care Managers
A geriatric care manager (GCM) is a professional with knowledge and expertise in older adult care and services issues. Usually, the GCM is a professional nurse or social worker. Geriatric care management usually involves an in-depth assessment of medical conditions, mental status, functional status, financial resources, and family involvement. This assessment considers the preferences of the older adults, the ability to live alone, the types of services needed to make that happen. Recommendations are then made and the GCM implements the services selected by the client and older adult.
The client is often an adult child of a frail older adult, and often one who cannot take time away from work or who lives a distance from the parent. However, clients are often attorneys, banks, and professional fiduciaries. The GCM services can range from simple to very complex with the Company making all of the arrangements for all services, monitoring the services provided to matching the older adult’s changing needs, to financial management and legal service arrangements. The best GCM companies are prepared for crisis management and have someone on call 24/7 to handle any potential emergency.
Geriatric care management services can be costly and typically not within the means of low-income older adults. (Neither Medicare nor Medicaid reimburses these fees.) On the other hand, quality care management can provide great peace of mind for the older adult and family members – particularly long distance family – as well as financial savings by proper planning for the future and matching the right service(s) with accurately identified needs based on comprehensive assessment.
At a minimum the geriatric care management company should be a member of the National Association of Professional Geriatric Care Managers http://www.caremanager.org/. Members of this professional organization would be aware of, and follow, the Geriatric Care Managers Standards of Practice. The NAPGM recommends asking the following questions when looking for a Professional Geriatric Care Manager:
- What are your professional credentials?
- Are you licensed in your profession?
- Are you a member of the National Association of Professional Geriatric Care Managers?
- How long have you been providing care management services?
- Are you available for emergencies?
- Does your company also provide home care services?
- How do you communicate information to me?
- What are your fees? (these should be provided in writing to the consumer/responsible party prior to services starting)
- Can you provide me with references?
You can look at the website example of one KC metro area Professional Geriatric Care Management Company and review their services at http://www.gltoyne.com/ccc/ccchome.htm then click on “Comprehensive Care Management” on the right side-bar.
Housing Options
A case manager should be familiar with the spectrum of housing options available to older adults in your local area. Housing options will vary from location to location.
The table below depicts possible housing options for older adults by the extent of assistance available in the setting. This table was published by Wacker et al (1998) and adapted from material from the AARP.
Spectrum of Housing Options
Housing Option
Little or No Assistance
Moderate Assistance
Cannot Perform Without Assistance
Single-Family Dwelling
Public Housing
NORC-Naturally Occurring Retirement Community
Housing Sharing
Home with:
Chore Services
Nutrition Services
Home Repair
Home Equity Conversion
Low-Income Energy AssistanceCongregate Housing
ECHO Housing Accessory Apartments
Home with:
Delivered Meals
Homemaker
Home Health Aide
Telephone Reassurance
Visiting ProgramsHome with Adult Day Services
Assisted Living/Personal Care Boarding Homes
Foster Care
Long-Term Care Facilities
Continuing Care Retirement Communities
Source:
Wacker, R.R., Roberto, K.A., Piper, L.E. (1998). Community resources for older adults: Programs and services in an era of change. (pp 301) Pine Forge Press.
The Older Americans Network
The Older Americans Act was enacted in 1965—the same year as Medicare. The OAA created a network to coordinate the local service system (some publicly funded, some privately funded) for older adults (age 60+) throughout the U.S. There are 670 Area Agencies on Aging throughout the U.S. Each is responsible for providing or contracting with other organizations to provide selected services for older adults in their service area.
Not all services are available in all areas. Some services may have waiting lists. Some services may be limited in nature. Area Agencies on Aging provide information to anyone, regardless of income status. For more information about the aging network in Kansas, please review the State of Kansas, Department on Aging’s web site: www.k4s.org/kdoa
The Older Americans Act Network is diagrammed below:
Consider a Social Worker as Part of Your Office Practice
If you are in private practice and you have a high proportion of older adults in your practice, you might seriously consider hiring a social worker to help patients identify and access community resources, for example: meals on wheels; friendly visitors; chore services; assistance with Medicare claims; legal services; senior center services and activities; referrals to home health agencies; referrals to hospice; senior housing options; transportation options; access to low-cost or no-cost wheel chairs, walkers, cans, commodes, etc. Social workers have many other skills as well, including: crisis management; assessment of abuse and /or neglect; substance abuse assistance; active listening; decision-making; communicating about difficult issues or topics; coping with psychosocial issues (i.e., grief, loss, fear, anger, depression, loneliness, etc.), and connecting people with resources in the community. Social workers also have advocacy skills. Social workers can be in practice with a bachelor’s degree (BSW) or a master’s degree (MSW). Clinical social work positions require the social worker to be licensed.
Hospitals, home health agencies, hospices and nursing homes have social workers on staff. Introduce yourself to the social workers in your practice area and talk with them about how they can help you provide excellent care to your older adult patients and families.
The Landon Center on Aging has a social worker who is available to all patients for assistance with accessing community resources.
Going Home from the Hospital
Mr B is an 82 year old widowed man who has broken his hip. He is cognitively intact and lived independently prior to this fracture. He is now walking with a walker and wants to go home. His daughter would like to have someone stay with him for a few weeks while he completes his recovery. She asks you to arrange home health services.
Questions
- Under what conditions does Medicare pay for home health care?
- What should you write on the referral?
- What is the cost for a live-in aid?
- Who pays for this cost?
Going to a Nursing Home
Mr Q is an 80 year old widowed retired college professor who has sustained a major stroke and is now unable to care for himself- he requires help to move in bed and to eat. He does not follow commands. He was previously cognitively intact and lived independently. His son would like for him to go to rehab and then have Medicare pay for any nursing home care he needs.
Questions
- Is Mr Q eligible for Medicare coverage for rehab or skilled nursing?
- How much does nursing home care cost per day under "private pay"?
- What is income/asset levels necessary to qualify for Medicaid?
Medication Coverage
Mrs. L is a 68 year old widowed retired woman who receives primary care from you. She lives independently in her own home and has Social Security and Medicare. Her current medications include Enalapril 5 mg daily, pravachol 20 mg daily, lansoprazole 30 mg daily and relafen 1000 mg daily.
Questions
- How much does this regimen cost per month?
- How much will Medicare Part D cover? Which resources can you direct her to for Part D assistance?
- Can you think of alternative therapies that might achieve the same benefits at lower cost?
©
The University of Kansas Medical Center
