Posts Tagged ‘healthcare’

Eldercare Locator – A Free, Public Service For Connecting Older Adults and Caregivers with Community Resources

October 27, 2010

The Eldercare Locator is a service of the U.S. Administration on Aging.  It’s been around for nearly 20 years.  Its toll free number is 800-677-1116.  Its website is http://www.eldercare.gov.  It  provides information about long-term care alternatives, transportation options, caregiver issues and government benefit eligibility.  This information is also available in Spanish and other languages.  There is an extensive database of links, publications, and other resources.

Medicare Coverage of Skilled Nursing Care – The Right Standard

October 18, 2010

I have heard, all to frequently, about people losing Medicare coverage for skilled nursing care because it had been determined that they had reached a “healing plateau.”    That is, they were not improving from the skilled nursing care they were receiving (and would not improve from additional skilled care) and, therefore, were deemed to be only receiving “custodial care”, not the skilled nursing services required for Medicare benefits.

While that may have been the standard in the past, it is not the standard today, but it still comes up.  As it did recently, when a federal judge ruled against the Social Security Administration and rejected  “Improvement” as a criterion for continuing Medicare skilled nursing facility (SNF) coverage.  Here is a summary of the case.

A federal district ruled that an administrative law judge (ALJ) with the U. S. Centers for Medicare & Medicaid Services (CMS) improperly denied Medicare benefits to a patient in a skilled nursing facility. The ALJ had concluded that “[i]t became apparent that no matter how much more therapy the Beneficiary received, she was not going to achieve a higher level of function.”

After undergoing hip replacement surgery on April 28, 2008, Mary Beth Papciak, 81, developed a urinary tract infection and was readmitted to the hospital. On June 3, 2008, Ms. Papciak was discharged by Dr. Tuchinda to ManorCare to receive skilled nursing care, physical therapy and occupational therapy. Upon Ms. Papciak’s admission to ManorCare, Ms. Papciak was unable to ambulate and could not use her walker due to numbness of her hands due to what was later diagnosed as carpal tunnel syndrome. Ms. Papciak also had a history of cellulitis, anemia, cholecystectomy, chronic atrial fibrillation, hypertension, anxiety and depression.

Ms. Papciak received therapy five days a week; however, she made slow progress during her stay. Her therapy included physical and occupational therapy, treatment, self care, therapeutic exercises and therapeutic activities. Her initial treatment was primarily for ambulation. Medicare paid for the skilled care Ms. Papciak received from June 3 through July 9, 2008. It was determined, however, that effective July 10, 2008, Ms. Papciak no longer needed skilled care because Ms. Papciak had made only minimal progress in some areas, had regressed in other areas, and had been determined to have met her maximum potential for her physical and occupational therapy. As a result, Medicare denied payment from July 10 through July 19 because Ms. Papciak was only receiving “custodial care,” not the skilled nursing services required for Medicare coverage.

Ms. Papciak appealed the decision denying coverage, and her appeal worked its way up the chain to an administrative law judge, which upheld the denial, which was then upheld by CMS’s Medicare Appeal Counsel (MAC). After exhausting her administrative remedies, Ms. Papciak sought relief in federal district court.

The federal district court sided with Ms. Papciak. The proper legal standard to be applied to a patient entitled to Medicare benefits in a skilled nursing facility is whether the patient needs skilled services to enable her to maintain her level of functioning.

In the CMS Medicare Skilled Nursing Facility Manual which sets forth the standard to be applied, the reviewing authorities must give consideration to a patient’s need for skilled nursing care in order to maintain her level of functioning. The relevant portion reads: “The services must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time, or the services must be necessary for the establishment of a safe and effective maintenance program.”

Neither the ALJ nor the MAC addressed Ms. Papciak’s need for skilled nursing care in order to maintain her level of functioning. This was error, held federal Magistrate Judge Cathy Bissoon, requiring that the decision to deny her benefits be overturned.

The ALJ had concluded that “[i]t became apparent that no matter how much more therapy the Beneficiary received, she was not going to achieve a higher level of function.” Similarly, the MAC stated that “[d]espite the appellant’s arguments to the contrary, the enrollee made little or no progress in therapy from the time of her admission to ManorCare through her discharge from skilled care on or around July 10, 2008.”

This is a common misunderstanding about Medicare’s skilled nursing facility benefit, that the patient must be showing “progress” in order for Medicare to pay for her care. Indeed, federal regulations state that “[t]he restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”

What happened to Ms. Papciak? She was hospitalized again, discharged to a different skilled nursing facility, where she received physical and occupational therapy under the Medicare benefit, and was discharged home on August 21, 2008.

Technology May Help Elderly Stay Home

August 9, 2010

In the general scheme of life, parents look after the children. But as parents age, the tables can turn. New technology is making it possible for adult children to closely monitor the daily movements and habits of their aging parents. The goal is to provide enough supervision to make it possible for elderly people to stay in their homes, which may be an emotionally and financially desirable alternative to moving to an assisted-living facility or nursing home.

Many of the systems are godsends for families. But, as with any parent-child relationship, loving intentions can be tempered by issues of control, role-reversal, guilt and a little deception. Just as the current population of adults in their 30s and 40s have a reputation of being hyper-involved, hovering parents to their own children, they now have the tools to micro-manage their aging parents.

You need to ask if this is something the parent wants. Monitoring technology for elderly people has been compared to the infamous “nanny cams,” hidden cameras some parents use to spy on their children’s babysitters. Needless to say, this can be very offensive to some.
Two recent articles, one from The New York Times and one from The Washington Post, explore some of the options available to families with aging relatives.

One choice is a GrandCare system, produced by a company of the same name based in West Bend, Wisconsin. It allows families to place movement sensors throughout a house. Information such as when doors are opened, what time a person gets into and out of bed, whether there’s been any movement in a room for a certain time period is sent out via e-mail, text message or voice mail. Costs vary depending on the features chosen, but this version costs about $8,000 to install plus monthly fees of about $75. That’s comparable to the cost of two months at an assisted-living facility.

Another monitoring alternative is a medication management system called MedMinder. It is basically a computerized pillbox. The parent’s correct daily dosages of different medications are arranged in boxes (usually by a nurse or other care provider). When it is time to take them, the pillbox beeps and flashes. If they are taken, you get a phone call or e-mail saying, essentially, Mom (or Dad) took her pills. If the pills aren’t taken within a two-hour window, the system starts nagging. It calls her. It flashes and beeps. Then you get a phone call with a message saying your mother missed her dose.

A small Virginia firm has unveiled a prototype of a portable, high-tech dwelling that would provide temporary shelter for a sick or elderly relative in the family’s back yard. It was created as an alternative to nursing homes as 78 million baby boomers head toward retirement. The company envisions that families could purchase or lease a MedCottage and set it up on their property, hooking it up to their home’s electrical and water supplies like an RV.MedCottage

The N2Care MedCottage is a 12-by-24-foot prototype filled with biometric technology that would allow a family and health-care providers to monitor the condition of an aging or disabled relative. The cottage contains air-filtration systems, video links, devices that allow the remote monitoring of vital signs and sensors that could detect an occupant’s fall.

Local zoning laws may pose one of the biggest obstacles to making such dwellings a practical solution to caring for aging family members in what it calls “accessory dwelling units.” Detractors have dubbed the concept the “granny pod” and predicted that it could create conflicts between neighbors who find the dwellings unsightly.

The MedCottage has some of the features AARP advocates in accessory dwelling units, but not all of the features that could be useful for people of all ages. It’s a step in the right direction. Other companies seeking to make similar structures are Seattle-based FabCab (whose name comes from Fabulous Cabin), and San Francisco-based Larson Shores Architects, which designs what it calls Architectural Solutions for the Aging Population, or ASAP.

Several studies have been undertaken to see just where the line between loving watchfulness and over-intrusion might be drawn. People don’t want to feel their privacy is compromised, and they tend to draw the line at cameras. The key seems to be control. The older person is much more amenable if he or she can control what information is available and who can access it. Ultimately, the decision must be made by the aging parent.

Finding at-home help for aging parents

July 20, 2010

When an older relative starts to need help to get through the day, many families want to avoid institutions. To keep their loved one at home, they need to either hire a home-care aide or become one.

There are two main kinds of in-home care. Personal or home-care aides provide companionship and support a person’s activities of daily living such as dressing, bathing, preparing meals and doing laundry. Home health aides may do all those things plus tasks such as administering medication or recording changes in a client’s condition. They also may work under a nurse’s supervision.

Here are questions to ask when thinking of hiring or becoming a caregiver.

What kind of care do you need and can you afford?
Before looking for a home-care worker, families need to make sure they can afford to hire one. Families typically pay for these services out of pocket unless the older person meets Medicare’s coverage conditions or has a private long-term care insurance policy that covers such needs.

If you don’t know what kind of care is needed, a specially trained geriatric care manager can help. Assessments cost about $500 to $800 depending where you live. The Alzheimer’s Association offers assistance with an always-open phone line at (800) 272-3900 and at www.Alz.org/carefinder. Medicare’s website has a Home Health Compare tool.

Rates from $14 to $22 an hour for non-medical in-home care are typical, but keep in mind that assisted-living facilities can run $2,800 to $4,400 a month. Agencies’ rates often are toward the top of the scale. Caregivers who work independently tend to be less expensive.

Should you hire an independent worker directly or go to an agency?
The advantage of using an agency is that it takes responsibility for paying wages, taxes and insurance. Agencies also run criminal background and driving-record checks, and provide back-up aides should the main caregiver get sick or go on vacation.

Families who decide to hire someone on their own should make sure they follow all state and federal employment laws, including any provisions for overtime pay. You don’t want someone going after your estate or the family member’s estate because something wasn’t handled correctly.

How do you find the right home-care aide for your needs?
Experts recommend interviewing at least six candidates. Families should interview applicants in the home so the aides know in what kind of environment they would be working. For example, having a smoker or pets in the home may be an issue. And don’t forget to include the elder’s input. Finally, don’t balk if someone who stands out is a little more expensive. Paying a little more for someone you really like is worth the extra cost.

Do you have a plan to take care of yourself?
If you’re caring for a loved one yourself, you need to plan time away to tend to your own physical, social and emotional needs. If you don’t, you risk health-draining burnout. Churches, synagogues and volunteer groups may offer short-term relief. Adult day-care centers may be another option. The Alzheimer’s Association and Agency on Aging groups also provide respite-care resources. For overnight breaks, check with assisted-living facilities, which may offer furnished rooms, meals and nursing staff on a temporary basis.

Family caregivers can find more resources at www.familycaregiving101.org, a website run by two non-profit organizations.

Health Insurance for Adult Children? Not so fast…

May 18, 2010

In late April I blogged about the new health reform law that goes into effect Sept. 23 allowing parents to keep an adult child on their health plan until age 26. But, what many people – my wife and me included – did not realize is that the new rules allow employers to wait until the start of the next plan year (typically January 1) before allowing parents to add adult children to their coverage.

We discovered this while looking into a short-term insurance policy for our 24-year-old son who is impacted by this law. We were quite surprised to learn the law is different than we first thought.

The period of time during which the new graduate will not have health insurance could be longer than first anticipated. Check with your insurance company or the administrator of your insurance plan to see if they are offering coverage during this gap. Even before the new rules kick in, many insurers are allowing graduating students to remain on their parents’ policy, but if your graduate will be dropped upon graduation, be sure to get a short-term insurance policy for them to cover the gap. Health insurance for young adults is relatively inexpensive. A policy with a high deductible for someone in their 20s can cost less than $100 a month in Wisconsin.

Health Care Reform: Health Insurance for Adult Children to Age 26

April 23, 2010

Effective September 23, 2010, the Patient Protection and Affordable Care Act requires group health plans and health insurers (who offer group or individual policies which cover dependents) to cover adult children on a parent’s plan until the child’s 26th birthday.   This has been trumpeted recently in the press, but there are a couple of things you need to know.

The child does not have to be a student or a dependent for tax purposes.  The insurance is not taxable to the child.  The term “adult child” for purposes of this requirement means a son, daughter, stepson, stepdaughter, or legally adopted or eligible foster child of the employee or insured. If your adult child has a child, there is no requirement to make coverage available to your grandchild.  Until 2014, this is only applicable to children who are not otherwise eligible to enroll in an employer-sponsored health plan.  If they are eligible, then they must use that insurance plan.

That it doesn’t go into effect until September presents problems for families with spring graduates.  There will be a period of time during which the new graduate will not have health insurance (between graduation and September 23rd).  Check with your insurance company or the administrator of your insurance plan to see if they are offering coverage during this gap.  Some insurance companies and plans are offering coverage because they are realizing the hassle and cost of dropping the new graduate and then re-enrolling them on September 23.  If your graduate will be dropped upon graduation, then be sure to get a short-term insurance policy for them to cover the gap.  Don’t take the risk.

Many states have existing laws which require insured plans to provide similar or more expansive coverage of dependents.  This new federal law will not change them and they will continue to apply.  Wisconsin is not one of those states.

Enroll for Medicare Online

April 20, 2010

The Social Security Administration (SSA) has just launched a new service that allows people to enroll online for their Medicare benefits even if they are not yet ready to file for Social Security benefits. About a half million Americans enroll in Medicare each year without applying for Social Security benefits.

The new online Medicare application makes it easier for people to enroll in Medicare. It saves a trip to the Social Security office, and you can complete the application at your own pace at home. The SSA says it takes less than 10 minutes to complete.

You can use the online Medicare application if you are at least 64 years and 8 months old, do not want to start receiving Social Security benefits in the next four months, and live in the U.S. or one of its territories or commonwealths. The application guides you through a brief set of questions that will help you consider either filing for Social Security and Medicare benefits, or filing only for Medicare. There are links to more information for people who have questions.

To use the new online application, click here.

Statistics – Long-term Care Insurance

February 12, 2010

I have discovered that getting good statistics on long-term care is equally as difficult as getting them for disability. After reading the New York Times article on disability statistics, I couldn’t help thinking that there might be the same problems with what was being said to encourage people to buy long-term care insurance. I made some inquiries and today I got a 137-page report on the subject from the Society of Actuaries.

I intend to read it this weekend. I’ll report back next week with my conclusions.

This is especially important to me because I am in the process of buying long-term care insurance for my wife and myself. As many of you may know, I have been an advocate of this insurance. Now I’ll be forced to reexamine my thoughts on the matter.

Continued Travails of a Baby Boomer

January 13, 2010

Like many, I get my health insurance through my spouse’s employer. It’s great coverage, but things really change when I turn 65 and am eligible for Medicare. I will no longer get coverage. That is not necessarily the result for all employer plans. You need to check the actual policy to be sure.

In any event, I have to make sure I have alternative insurance in place when I turn 65. I don’t want to be like a client I once had who also lost coverage at 65 and assumed that he was automatically enrolled in Medicare. He continued to work and did not apply for Social Security. About three months after turning 65, he had a major medical problem that cost tens of thousands of dollars. That’s when he found out that he did not have insurance and did not have Medicare. He was on the hook for all of it. Needless to say, it put a dent in his retirement plans.

Medicare has four components: Part A is hospital insurance, Part B is medical insurance (physicians, outpatient services, medical supplies and home health care), Part C is the alternative option of managed care, and Part D is the prescription drug benefit.

People are automatically enrolled in Part A when they apply for Social Security. For people like me who are not going to apply for Social Security until later, there is a separate Medicare application. I intend to get started on that application at least 90 days before I turn 65.

I am also going to get Part B. It’s not hard because everyone who gets Part A is automatically enrolled in Part B. You have to decline enrollment if you don’t want it. I am going to enroll in Part B (regardless of whether or not there is coverage under my wife’s insurance at that time) because there is a 10 percent penalty tacked on to the premiums for each 12 months of delay after age 65. I don’t want that additional cost later.

Besides Medicare, I am going to get long-term care insurance and a medigap policy. A medigap policy is health insurance sold by private insurance companies to fill the gaps in Medicare plan coverage. Medicare does not have any really effective benefits for long-term care, whether in the home, assisted living, or a nursing home. Medicare has gaps in coverage (some great names for them… donut holes). These policies will address those gaps.

We are all waiting anxiously for the outcome of the continuing healthcare debate in this country. It’s likely to go on for quite some time. But these are my conclusions for handling the baby boom problem, especially if you are not retiring at 65.

“It takes as much energy to wish as it does to plan.” – Eleanor Roosevelt