Life After 50 Expo

Dear Marci,

As my spouse and I grow older, it has been more difficult for me to help take care of him. It would be really helpful to have an aide come to our home and help with his personal care. Does Medicare cover long-term care?

-Remi (Point Marion, PA)

Dear Remi,
Unfortunately, Medicare usually does not cover long-term care (LTC) services.

LTC refers to a range of services and supports that help you perform everyday activities. LTC can be provided in your home, a nursing home, an assisted living facility, or other setting, and may include medical care, therapy, 24-hour care, personal care, and custodial care (homemaker services).

Just because something is not covered by Medicare, though, doesn’t mean it isn’t needed. There are other ways you can receive this help. Let’s discuss a few:

Medicaid is a state and federal program that provides health coverage if you have a limited income. Medicaid is the country’s largest payer of LTC services and will pay for nursing home care. Medicaid benefits also coordinate with Medicare. While Medicaid can vary from state to state, all states should have a Medicaid program that covers long-term care for those who need care at home and those who need long-term care in a nursing home. Call your local Medicaid office to learn if meet the eligibility criteria in your state.

An Area Agency on Aging (AAA) may be able to provide counseling and connect you with low-cost services in your area.

Local senior centers may have programs that can deliver meals, provide transportation and shopping assistance, and offer case management. To find senior centers in your area, call your local AAA or use the Eldercare Locator tool.

Faith-based organizations and charities may offer services, financial assistance, and/or referrals to other organizations in your area.

Geriatric care managers are health and human services professionals who work privately with you and your family to create a plan of care that meets your needs.

While Medicare does not cover long-term care, it does cover home health care. Under the home health benefit, Medicare pays in full for an aide if you require skilled care (skilled nursing or therapy services). A home health aide provides personal care services, including help with bathing, toileting, and dressing. However, Medicare will not pay for an aide if you only require personal care and do not need skilled care.

In other words, if your spouse needs skilled nursing care or therapy services in addition to personal care, Medicare may cover the cost of an aide. If you are unsure what kind of care your spouse needs, start by speaking with his health care provider.

I hope this helps with your and your spouse’s situation. You can also contact your State Health Insurance Assistance Program (SHIP) for more counseling.

-Marci

During the summer months, older adults are at a significantly increased risk for hyperthermia, the name for heat-related illnesses. Hyperthermia can include heat stroke, heat edema (swelling in your ankles and feet when you get hot), heat syncope (sudden dizziness after exercising in the heat), heat cramps, and heat exhaustion.

The National Institute on Aging makes these suggestions for avoiding hyperthermia:

Stay indoors on particularly hot or humid days.

Drink plenty of liquids and wear light-colored, loose-fitting clothes in natural fabrics.

If you do not have a fan or air conditioner, go somewhere else that is cool. A local senior center may provide a cooling center, or you can to a public air-conditioned place like a mall, movie theater, or library.

Look for symptoms of heat stroke, which include fainting, a change in behavior, dry, flushed skin with a strong and rapid pulse, lack of sweating. If you believe someone is suffering from heat stroke, call 911.

Dear Marci,

I recently enrolled in Medicare and learned that Medicare does not cover dental care. Why is this? And how should I receive dental care then?

-Brody (Dallas, TX)

Dear Brody,
Yes, dental care is excluded from Medicare coverage.* Medicare is health insurance that exists because of federal laws that were passed to create it. Initially, as created in 1965, Medicare consisted of Part A and Part B and reflected the restrictions and limitations of most health insurance at that time. (Some additions have been made over time, including prescription drug coverage through Part D.) The federal law that created Medicare benefits has specific provisions that exclude coverage for certain things, like dental care and routine vision services.

Just because something is not covered by Medicare, though, does not mean that it is not needed. You may be able to get assistance through the programs listed below:

· Medicare Advantage Plans: Some Medicare Advantage Plans offer routine dental coverage. Contact your plan to learn about services it may cover, any rules or restrictions, and costs. If you are considering joining Medicare Advantage, make sure the plan suits your other care needs.

· Medicaid: In some states, Medicaid covers some dental services. You may qualify for Medicaid if you have a low income and minimal assets. Contact your local Medicaid office for more information.

· Private stand-alone dental plans: You can purchase a separate dental plan from a private company.

· Reduced-cost or free dental clinics: These clinics are available in many states. Use resources available at NeedyMeds, healthcare.gov, freeclinics.com, and hhs.gov for more information.

· Local hospitals: Call the hospitals in your area to ask if they offer dental clinics, how you can become a patient there, which services they offer and at what cost, and if payment plans are available.

· Federally Qualified Health Centers (FQHCs): FQHCs are health care facilities located in medically underserved areas. People with Medicare are eligible to receive services from an FQHC. Some FQHCs may offer dental care.

· Community Health Centers (CHCs): CHCs provide free or reduced-cost health services, including dental care. CHCs are funded by the Health Resources & Services Administration (HRSA).

· Dental schools: Some dental schools provide low-cost dental care. Dental students work with patients under the supervision of experienced, licensed dentists.

To learn about local resources, you should either contact your State Health Insurance Assistance Program or use the government’s Eldercare Locator tool.

*Note: While Medicare does not cover dental services that you need primarily for the health of your teeth, it does offer very limited coverage for dental care needed to protect your general health. Read more here.

I hope this helps!

-Marci

Dear Marci,

My father began hospice care a few weeks ago. It seems that staff from the hospice agency have been coming to his home less and less, though… Is this hospice fraud?

-Viraj (Boston, MA)

Dear Viraj,
As we discussed in our last newsletter, hospice is a program of end-of-life pain management and comfort care for those with a terminal illness. Medicare’s hospice benefit is primarily home-based and covers end-of-life palliative treatment, including support for one’s physical, emotional, and other needs. It is important to remember that the goal of hospice is to help an individual be as comfortable as possible, not to cure an illness.

Hospice fraud occurs when Medicare is falsely billed for any level of hospice care or service. As the family member of a Medicare beneficiary, you should look out for suspicious behavior from health care providers that might indicate Medicare fraud or abuse.

Report potential hospice fraud, errors, or abuse if you or a loved one are:

Being abused or neglected by a hospice worker

Receiving inadequate or incomplete services

Not receiving the services and care outlined in your doctor’s plan of care

Falsely certified as being terminally ill in order to qualify for the hospice benefit

Enrolled in hospice without your or your family’s permission

Offered gifts or incentives to receive hospice services or to refer others for hospice services

Have your medication stolen by a hospice worker

Billed for a higher level of care than was needed or provided, or for services not received (you can find this information on your Medicare Summary Notice or Explanation of Benefits)

Experiencing high-pressure and unsolicited marketing tactics of hospice services

Kept on hospice care for long periods of time without medical justification

To report potential hospice care fraud, errors, or abuse, you should contact your local Senior Medicare Patrol (SMP). Your SMP can also help you identify possible concerns. Find your local SMP by visiting www.smpresource.org or calling 877-808-2468.

-Marci

Dear Marci,

My mother-in-law has a terminal condition and is nearing the end of her life. I’m helping her figure out the logistics of hospice care but do not know how her Medicare will cover it. How does Medicare cover hospice?

-Dottie (St. Johns, MI)

Dear Dottie,
I’m so sorry to hear about your mother-in-law’s health. I hope the following information with be helpful to you and your family during what I imagine is a very challenging time.

Hospice is a program of end-of-life pain management and comfort care for those with a terminal illness. Medicare’s hospice benefit is primarily home-based and covers end-of-life palliative treatment, including support for one’s physical, emotional, and other needs. It is important to remember that the goal of hospice is to help an individual be as comfortable as possible, not to cure an illness.

To elect hospice, someone must:

Be enrolled in Medicare Part A

Have a hospice doctor certify that they have a terminal illness, meaning a life expectancy of six months or less if the illness takes its normal course

Sign a statement electing to have Medicare pay for palliative care (pain management), rather than curative care

And, receive care from a Medicare-certified hospice agency

Once an individual chooses hospice, all of their hospice-related services are covered under Original Medicare, even if they are enrolled in a Medicare Advantage Plan, unless their Medicare Advantage plan is part of a specific demonstration program, in which case the plan will pay for hospice care. Their Medicare Advantage Plan will continue to pay for any care that is unrelated to their terminal condition. Original Medicare payments to the hospice provider also cover any prescription drugs needed for pain and symptom management related to the terminal condition. The individual’s stand-alone Part D plan or Medicare Advantage drug coverage may cover medications that are unrelated to their terminal condition.

The hospice benefit includes two 90-day hospice benefit periods followed by an unlimited number of 60-day benefit periods The doctor must recertify the person’s terminal illness before each benefit period.

If someone you care for is interested in Medicare’s hospice benefit:

Ask their doctor whether they meet the eligibility criteria for Medicare-covered hospice care.

Ask their doctor to contact a Medicare-certified hospice on their behalf.

Be persistent. There may be several Medicare-certified hospice agencies in your area. If the first one you or the doctor contact is unable to help, contact another.

Once you have found a Medicare-certified hospice:

The hospice medical director (and the individual’s regular doctor if they have one) will certify that they are eligible for hospice care. Afterwards, the individual must sign a statement electing hospice care and waiving curative treatments for their terminal illness.

Their hospice team must consult with the individual (and their primary care provider, if they wish) to develop a plan of care. Their team may include a hospice doctor, a registered nurse, a social worker, and a counselor.

I hope this helps you and your mother-in-law know where to start with getting Medicare-covered hospice care.

-Marci