Crawford Care Management

Long Term Care Resources

For many Americans, a major cause of worry is whether they will have enough resources to care for themselves when they get older. The purpose of this article is to highlight several resources available to address long term care needs, though each has its limitations. Delivery systems are often not attuned to the chronic care needs that older adults face and none, it seems, are easily accessible. Some guidance may be needed to navigate rules for eligibility, and planning ahead always has value. This overview is not intended to replace the detailed information available from the sources that administer each of the programs cited.

Medicare is insurance for medical treatment. It does not pay for preventive care, except certain diagnostic tests. Medicare is a health insurance program for people 65 and older, some people with disabilities, or people with end-stage renal disease. Original Medicare Plan coverage has two parts: hospital insurance (Part A) and medical insurance (Part B).

Those who paid Medicare taxes while working, and their spouses, do not have to pay a monthly premium for Part A coverage. There is a monthly premium for Part B coverage. If you choose to enroll in Part B, the premium is usually taken out of your monthly Social Security, Railroad Retirement, or Civil Service Retirement pay. If you do not get any of these payments, Medicare sends you a bill.

Medicare + Choice
Medicare offers you options for getting your Medicare benefits. One option is the Original Medicare Plan (see above). In addition, some private companies contract with the Medicare program to offer Medicare + Choice ("Medicare plus Choice") plans. 
Medicare + Choice plans provide care under contract to Medicare. They may provide benefits like coordination of care or reducing out-of-pocket expenses. Some plans may offer additional benefits, such as prescription drugs. 

Medigap, or Medicare Supplement Insurance, is health insurance sold by private insurance companies to fill the gaps in Original Medicare Plan coverage. These policies cover individuals, not dependents. To purchase a Medigap policy, through monthly premiums, you generally must have Medicare Part A and Part B.

If you are in the Original Medicare Plan and have a Medigap policy, you can usually go to any doctor, hospital, or other health care provider who accepts Medicare. However, if you have the type of policy called Medicare Select, you must use specific hospitals and, in some cases, specific doctors to get full insurance benefits.

Medigap policies only help pay health care costs if you have the Original Medicare Plan. You don't need to buy a Medigap policy if you are in a Medicare + Choice Plan.

Medicaid is a program mandated by the federal government, administered by the state, and funded by both. Coverage may vary from one state to the next. If you are eligible, Medicaid pays for primary care in a doctor’s office, inpatient care in a hospital and medications. It also covers custodial care for the chronically ill and disabled in nursing homes and community settings.

Medicaid is provided for low-income individuals who would not otherwise be able to pay for healthcare. It is a means-tested health care and long term care insurance program, available to those who fall within certain income and asset limitations. Some assets, like a home, car, personal belongings and life insurance are excluded from the means-test calculation. In general, however, one must qualify as “low income,” as defined by federal and state regulations, to become eligible for benefits.

Social Security Disability Insurance
Under Social Security Disability Insurance provisions, disability benefits are available to qualified disabled workers and dependents. To qualify one must have a sufficiently long and recent work record. Disability benefits continue until one recovers or returns to work.
Disability under Social Security is based on your inability to work. Disability is considered the inability, because of a medical condition, to do work that one could do before. The amount of your monthly disability benefit is based on your lifetime average earnings covered by Social Security.

Private Health Insurance
Health insurance programs, through employers or unions, help pay for care that a person may not otherwise afford by spreading the financial risk among many and minimizing the financial risks associated with catastrophic illness.

These health benefit offerings may vary depending on status (i.e. regular full-time employee versus regular part-time employee). Each plan is different, but coverage is usually available for office visits to primary care physicians and specialists, hospital admissions, outpatient surgery and emergency room visits. In addition to monthly premiums, co-pays (initial participant out of pocket expenses) and co-insurance (portion paid by the insurance company; and portion paid by participants up to an annual maximum) apply. Coverage may require use of in-network doctors and hospitals. Coverage usually includes routine preventive care and a prescription drug plan.

Some employer and union-provided health insurance policies can continue or switch over to provide coverage for you when you are 65 and retired.

Private health insurance may pay for health care costs not covered by Medicare. They may also be primary payors for Medicare beneficiaries who have elected coverage under the Medicare + Choice program.

Long Term Care Insurance
Long term care insurance policies, offered by private companies, are designed to cover the cost of nursing home stays without the prior need for a stay in the hospital, home care without requiring a prior stay in a nursing home, adult daycare, assisted living, hospice care and alternate care.

Qualification for benefits is based on the inability to perform a specified number of activities of daily living (ADL). The most common ADL’s are bathing, eating, toileting, dressing, ambulating (with or without supports like canes, walkers or wheelchairs), transferring in and out of bed or in and out of a chair, and continence. Compare policies carefully. All policies must offer an inflation rider and guaranty renewal if you make your payments on time, however benefit periods, waiting periods, and benefits levels vary. Good benefits for home health care may, in fact, make it possible for you to stay at home, and avoid nursing home care.

Personal Income and Assets
More than one-third of long term care financing comes from private pay, while Medicare, Medicaid and other insurance programs pay the remainder. Because you may not qualify for age-based, entitlement, or needs-based programs to meet all your needs, some consideration must be given to “self-funding” of care needs. And what public programs don’t provide, you will have to provide for from your own financial resources. Savings, stocks, bonds, real estate, mutual funds, annuities, and life insurance are all potential vehicles for funding a level of care that may mean the difference between independent living and nursing home assistance.

Some life insurance policies allow an “accelerated death benefit,” in which up to half of the death benefit may be available to the policyholder who becomes terminally ill. Viatical settlements offer another means to turn potential assets into cash. In this arrangement, a policyholder sells his life insurance policy to an investor for less than its face value. The policyholder can then use the cash to pay for care or other needs and the investor makes a profit when the policyholder dies.

Your home is a financial asset and you may consider selling it as a means of obtaining funds to pay for needed care. Another option is also available. A reverse mortgage can make the value one has built up in a home available to pay for long term care expenses. Instead of making a payment to a bank or lender every month, the lender makes a payment to you. You do not have to pay back the loan as long as you live in the home. If you qualify, you can continue to own or live in your home and receive payments for doing so. Repayment is typically due when the owner dies or when the home is sold.

Another way to look at your home is that it is your primary long-term care location – one that you would like to reside in as long as possible. Your home can support the caregiving effort when you make it as user-friendly as possible, install shower stall rails and chairs, improve lighting, ensure adequate heating and ventilation, facilitate access to the front door or upper floors, install safety features [fire extinguisher, smoke detector, automatic shutoff tea and coffee makers], install less accident-prone types of flooring, replace faucets and door handles with lever handles, reorganize cabinets putting everything with in easy reach, reduce the need to enter the basement or attic areas, and replace furniture which is difficult to use or uncomfortable. Assistance for home modifications may be available to low or middle income homeowners.

Community Resources
Communities, towns, cities, states, and counties organize to serve residents. Through community financial support, organizations offer food, clothing, shelter, day care services, counseling, health screening and education, transportation, and money to those in need. Some services, like information and support groups or information and referral services, are also targeted at family, friend and informal caregivers.

States may offer personal care attendant programs, pharmacy support, and home care services for the elderly. Churches, charities, and civic groups are potential long term care resources as well.

Programs of All-Inclusive Care for the Elderly (PACE)
PACE provides medical, social, and long-term care services for frail people and is available through 25 PACE sites in states that have chosen to offer it under Medicaid [CO, CA, MA, MD, ME, MI, MO, NY, OH, OR, SC, TN, TX, WA, WI]. To be eligible, you must be over 55, live in a PACE area, meet the State’s standards for nursing home care, and be able to live safely in the community. A team of health professionals deliver all services through a health care plan. For most patients, services permit them to continue to live at home.

PACE receives a fixed monthly payment per enrollee from Medicare and Medicaid. Persons enrolled in PACE also may have to pay a monthly premium, depending on their eligibility for Medicare and Medicaid.

Pharmaceutical Assistance Programs
Some pharmaceutical companies offer assistance with prescription drugs. These are private assistance programs. They have specific eligibility requirements and are usually offered nationally. Assistance is offered to U. S. residents with annual household income below a defined level (varies for each company). Periodic reapplication may be required.

Tricare for Life
Tricare for life provides expanded medical coverage for Medicare-eligible military retirees, and their spouses/survivors, including retired guard members and reservists. You must have Medicare Part A and Part B to be eligible for Tricare for Life.

Veterans Benefits
The Medical Benefits Package emphasizes preventive and primary care, offering a full range of outpatient and inpatient services to all enrolled veterans. Coverage varies based on the presence of service-connected disabilities and other factors. A new web site will soon be available with information about hospice care, home based primary care, geriatric evaluation and management, domiciliary care, Alzheimer's/dementia program, adult day health care, and respite care.

You are, perhaps, your own most important long-term care resource. No care plan can be effective unless you understand it and are contributing to it. You must be communicating your experiences and needs before anyone can respond to them. Your input and approval of any action plan are essential to its initiation.

Your adherence and compliance with a treatment plan are critical to its success. Maintaining control of your own independence is your incentive to act. Judith E. Heumann, Cofounder of the World Institute on Disability said, “Independent living is not doing things by yourself; it is being in control of how things are done.”