Download Introduction to Medicare, Medicaid and Community Services

The Einstein Geriatrics Fellowship
Core Curriculum
The Einstein Geriatrics
Fellowship Core Curriculum
• A 20 part lecture series designed for first
year geriatrics fellows
• Covers the ACGME content areas for
fellowship training
Introduction to Medicare,
Medicaid and
Community Services
Amy R. Ehrlich, MD
Debra Greenberg, PhD, MSW
Division of Geriatrics
Albert Einstein College of Medicine
Montefiore Medical Center
Objectives
1. Describe the benefits available to older adults
through Medicare part A, B,D in the outpatient,
inpatient and LTC setting.
2. Understand the Medicaid income requirements
and available benefits.
3. Recognize 2-3 additional community services
available to older adults.
Case-1994
• Mrs. R is a 75 yr. old African American female
• Active medical problems:
– Mechanical mitral valve for which she is
anticoagulated
– OA of the hips
– Macular degeneration
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© Annie Levy, 2008
• SH: Widowed. Retired secretary for a state
agency. She lives in a town-house that she
owns. Her son and his family live nearby.
• Finances:
– $2,000 /month from a pension and SS
– $200,000 savings
• She is currently managing well in the
community. She is active in her church and
attends cultural events with her friends.
Advancing Age:
Functional Decline and Dependency
• Dementia
• Functional disability
• Sensory impairment
Disability in Community
Dwelling Older Adults
AGE
80
60-69
70
70-74
Percent
60
50
75-79
40
80+
30
20
10
0
Any Disability
Severe Disability
Needs Assistance
US Census Bureau
2000
Activities of Daily Living
(ADL)
• Feeding
• Bathing
• Toileting
• Transferring
• Dressing
Instrumental Activities of Daily
Living (IADL)
• Cooking
• Cleaning
• Laundry
• Shopping
• Telephone & transportation
• Managing medicines
• Managing money
Advancing Age
Increased functional decline
Increased cognitive decline
Sensory impairment
Increased dependency
MEDICARE
&
MEDICAID
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www.oheweb.com/images/flags/dsc01186.
Medicare
• Federal program
• Eligibility:
– Age > 65
– U.S. citizen or a permanent resident
– Lived in the U.S. continuously for a five-year
period
– Worked for > 10 year period (or had spouse or
child who worked)
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www.seniorhelpforum.com
Medicare
•
•
•
•
Part A-Hospital Insurance
Part B-Medical Insurance
Part C- Medicare Advantage “private insurance”
Part D-Prescription Drug Coverage
Medicare Part A:
Hospital
• Deductible: $1,132/year
• Co-payments:
– Hospital day 1-60
– Hospital day 61-90
– Hospital day 91-150
– Each day beyond 150
Fully covered
$283/day
$566/day
No coverage
Maximum Minimum
Medicare Part B
Medical Insurance Premiums
INCOME/yr.
PREMIUM/yr.
Individual
< $82,000
$1,150
Couple
<$170,000
Individual
>$210,000
Couple
>$430,000
$3,700
“Medi-Gap” Insurances & HMOs
• Additional insurance that covers “gap”
between what Medicare pays and cost of
services
or
• Capitated services that assign a “gatekeeper” physician
Medicare Part B
• Office visits
• 80% (20% co pay)
• Lab tests
• 100%
• Diagnostic tests (CT,MRI) • 80% (20% co pay)
Medicare Coverage
• Transportation
• Emergencies
• Hospital to SNF
• Hearing aids
• Eye glasses
• Dental
• Not covered
• Post-operative-80 %
• Not covered
Medicare
HA Coverage
• Long term HA
• Short term HA
Medicare
HA Coverage
• Long term HA • Not covered
• Short term HA • With skilled need- up to 20 hrs/wk.
Medicare
Sub-Acute Rehabilitation
• Sub-Acute Rehab
• up to 20 days-100 %
• 21-100 days-$141.50/day
• >100 days-no coverage
Long Term Care = Nursing Home
• No Coverage
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eldercareabcblog.com
Hospice
• Terminally ill with a prognosis < 6 months.
• Patient choose to receive care from a
hospice
• Essentially all costs of terminal illness are
covered including medications,
transportation, home aids (20 hrs/week),
inpatient respite care, bereavement services
Medicare Part D
Prescription Plan
•
•
•
•
•
Mandated in 2006
Monthly premium/ co-pay vary
Multiple different plans/ formularies in some states
Plans and formularies change annually
Coverage:
–
–
–
–
75% of cost: $2,500
No coverage: $2,500-$5,700 “ Donut Hole”
100% of cost > $5,700
State programs and MediGAP plans may cover the donut
hole.
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businesspundit.com
Medicaid
• State program based on poverty level
• Benefits vary dramatically from state to state
• Two categories of eligibility:
– Age > 65 or < 18 years old
– Or on Public Assistance
Image:
health.state.ny.us
Medicaid Eligibility-NY
• Income limit
– Individual: $767/month
– Couple: $1,117/month
• Resource limit
– Individual: $13,800
– Couple: $20,100
– Exemptions: $1,500 per person for burial fund, home,
car, health insurance premiums.
– Can continue in your own home but home is an asset.
• 5 year “look-back”
Spousal Allowance-NY
• Community spouse allowances when other
spouse is institutionalized:
SPOUSE
• Income:
• Resources:
$2,739/mo
$109,560
Medicaid Coverage-NY
•
•
•
•
Hospitalization
Office visits
Lab tests
Diagnostic tests (CT,MRI)
•
•
•
•
100%
100%
100%
100%
Medicaid Coverage-NY
•
•
•
•
•
Medications
Transportation
Hearing aid – one ear
Eye glasses
Dental
•
•
•
•
•
Co-pay: $1/$3
100%
100%
100%
100%
Medicaid Long Term Care
Coverage-NY
•
•
•
•
•
Long term Home Attendants
Short term Home Attendants
Day programs
Sub-Acute Rehab
Nursing homes
•
•
•
•
•
100%
100%
100%
100%
100%
CASE
1994: 75 yr old female on coumadin with
macular degeneration and OA hips.
•Finances:
–$2,000 /month from a pension and SS
– $200,000 savings
Medicare and MediGAP from her
employer. Not Medicaid eligible.
2002: 8 Years Later
• 83 years old on coumadin for an MVR.
• She has developed a worsening gait disorder,
progression of her macular degeneration and
mild cognitive dysfunction.
• She got her medications mixed up and stopped
her lasix.
• In the setting of worsening edema she fell at
home and developed a superficial laceration of
her LE with a cellulitis.
Community Referral to a
Home Health Agency
• Medicare covered benefit
• Home care team:
– Nursing, Physical Therapy, Occupational Therapy,
Speech Therapy, Social Work
• Medicare requires a “Skilled Need”
– Nursing, Physical Therapy or Speech
– Once referral initiated, entire team can become
involved for evaluation
• Diagnosis for referral might include:
– Gait disorder, falls, medication compliance, wound
care, patient education
Home Health Agency
• Nursing :
– wound care, medication mgt
• Physical Therapy:
– Gait and balance training,
– Adaptive equipment: grab bars, tub seat,
raised toilet seat
• Short term home attendant:
– 4 hrs/day for 5 days a week to help with
personal care for 1 month
2004:
10 Years Later
• Ms. R is now 85 years old.
• Her functional has slowly worsened and she
begins to lose weight.
• She is having trouble taking the bus to
doctor’s appointments and to have her INR
checked.
• She has more difficulty shopping and
cooking for herself.
Community Services
• Access-A-Ride
• Department for the Aging Programs:
– Meals on Wheels
– Senior Center: hot lunch programs
• Personal Emergency Response System (PERS)
– Pay privately $25/mo after installation costs
– Medicaid may cover under special circumstances
Specialized Community Services
• Services for visually impaired
– Library of Congress: Books on Tape
– The Lighthouse
– Jewish Guild for the Blind
Mrs. R.
• Ms. R’s weight stabilized with the addition
of Meals on Wheels.
• She started using Access-A–Ride.
• She purchased a PERS.
2007 :13 Years Later
•
•
•
•
Mrs. R is now 88 years old.
Her gait deteriorated and she has fallen
multiple times on coumadin.
She begins having trouble getting into the
shower.
• Her cognitive status deteriorates and she
can no longer manage her medications
without direct supervision.
Options
• Pay for help privately
• Spend down for Medicaid eligibility
Private Pay Help
• Agency fees for 24 hr. care:
• $230/day
$6,900/month
$82,800/year
• She will deplete her savings in less than
3 years and be Medicaid eligible with a
monthly “spend-down.”
Medicaid Community Services
•
•
•
•
HA up to 24 hrs/Day
Day programs
Night time “Sun-downing” programs
Long Term VNS Programs or “Nursing Homes
without Walls”
• Managed Medicaid Programs like
Comprehensive Care Management (CCM)
• Respite Care
2009: 15 Years Later
• Mrs. R is 90 years old.
• She has had progressive cognitive and
functional decline.
• She is almost completely blind. She
has difficulty rising from a chair
without the assistance of another
person.
• She had one hospital admission for a
fall with extensive hematoma.
•She privately pays for 8
hours/day of help at $15/hr. and is
alone at night which makes her
family anxious.
•She continues to go to her church
and is involved with her friends
and family.
•She came to clinic last week for a
routine appointment.
•Her goal is to stay at home for the
rest of her life.
Conclusion
• Marked demographic shifts in the aging of
America
• Aging brings increased prevalence of
cognitive and functional decline
• Complex structure of both medical
insurance and community services available
for our aging patients
QUESTIONS?