Albert Einstein College of Medicine



Albert Einstein College of Medicine

Amy R. Ehrlich, MD

Debra Greenberg, PhD, MSW

Einstein Geriatrics Core Curriculum Speaker’s Notes:

Introduction to Medicare, Medicaid and Community Services

NOTE TO SPEAKERS: You will need to review the Medicaid requirements and programs in your state and community and modify the slides as needed.

Speaker’s Notes Slide #1:

The goal of this lecture is to provide an introduction to the financial structure and benefits available to older adults through Medicare and Medicaid. The lecture additionally covers a brief review of the demographics and definition of disability and select services that are available through community agencies.

Speakers Notes Slide #2:

After completing this lecture you should be able to:

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.

• This is neither a health policy talk nor a political discussion about what should or should not be changed in this country. Rather the hope is that you will come away understanding what is actually available to patients in the current system. These programs change from year to year and vary widely across different states.

• Many Geriatricians work closely with social workers and other health care professionals who have a very detailed and in-depth understanding of this topic.

• However, physicians and physicians- in- training must have broad understanding of the current entitlements, structure of health insurance and social service programs available in the community in order to understand the challenges facing patients.

• This talk presents a broad and basic overview of the current programs. There is a tremendous amount of information and detail available on-line and I would encourage you to use additional resources.

Speakers Notes Slide #3:

NOTE TO SPEAKERS: Be prepared to explain what a pension is to the learners depending on their background in US history and economics. A pension is an arrangement to provide people with a secure income when they are no longer earning a regular income from employment. The number of jobs that offer traditional pensions have dropped dramatically over the last 20 years in the US.

• We are going to start with an actual case of a patient and follow her over time.

• Mrs. R is a 75 yr. old African American female

• Active medical problems include:

➢ Mechanical mitral valve for which she is anticoagulated

➢ OA of the hips

➢ Macular degeneration

Speakers Notes Slide #4:

• Social History: Widowed. Retired secretary for the state school department. She lives in a town-house that she owns. Her son and his family live nearby.

• Finances:

• $2,000 /month from a pension and Social Security.

• $200,000 savings

• She is currently managing well in the community. She is active in her church and attends cultural events with her friends.

• We will now follow Mrs. R over the next 15 years as she develops increasing levels of functional decline and dependency. We will explore what services are available to her through her medical insurance and community services.

Speakers Notes Slide #5:

Advancing age brings with it increasing functional decline and dependency. This includes increased prevalence of

➢ Dementia

➢ Functional disability

➢ Sensory impairment

Speakers Notes Slide #6:

In the 2000 census questions were added about disability. Over 1/2 of community dwelling older adult report having at least some type of disability (physical or non physical). The prevalence of disabilities rises sharply with age. Over half of persons aged 80 and older report one or more severe disabilities. Approximately 1/3 of the old-old living in the community require the assistance of another person for their Activities of Daily Living (ADLs).

Speakers Notes Slide #7:

To briefly review:

Activities of Daily Living (ADL) are defined as self-care activities that are required to maintain oneself. They include:

• Feeding

• Bathing

• Toileting

• Transferring

• Dressing

Instrumental Activities of Daily Living (IADL) are not required for daily functioning but are required to live INDEPENDENTLY in the community. They include:

• Cooking

• Cleaning

• Laundry

• Shopping

• Telephone & transportation

• Managing medicines

• Managing money

Speakers Notes Slide #8:

Advancing age brings with it increased functional and cognitive decline and sensory impairment all which lead to increased dependency. With this brief overview we are now going to turn to the two largest providers of medical benefits for older adults in the US-Medicare and Medicaid.

Speakers Notes Slide #9: N/I

Speakers Notes Slide #10:

Medicare is a Federal program. It is essentially the same across all state lines.

Eligibility criteria include:

• 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)

Speakers Notes Slide #11:

Medicare is broken down into four components:

• Part A-Hospital Insurance

• Part B-Medical Insurance

• Part C- Medicare Advantage “private insurance”

• Part D-Prescription Drug Coverage

Speakers Notes Slide #12:

Medicare Part A:

• Is Medicare that covers hospitalization.

• Most physicians don’t know much about Medicare Part A and that is because for the most part, expenses related to an acute hospitalization are covered by Medicare. Providers tend to know and the costs which are UNCOVERED and which their patients have trouble paying for and therefore discuss with the providers or alternatively influence the way providers end up making decisions.

• Deductible for Medicare Part A is approximately $1,132/year

• Co-payments which patient is responsible for include:

• Hospital day 1-60: Fully covered

• Hospital day 61-90:$283/day

• Hospital day 91-150: $566/day

• Each day beyond 150: No coverage

• So hospitalizations are fully covered except for the deductible for 60 days.

• Additionally, there are 60 “lifetime reserve days” that resume after the 90th day.

• So essentially cost in the hospital never comes up except under very rare circumstances. This is why you don’t think about costs.

You only think about length of stay (LOS) because that’s how the hospital is paid.

Speakers Notes Slide #13:

Medicare Part B is what we think of as traditional Medical Insurance.

• The cost of the insurance premiums is as follows.

• For an Individual making < $82,000 /year they pay $1,150/year.

• For a couple making < $170,000/ year they pay $1,150/year.

• Wealthy Americans pay somewhat more for Medicare Part B.

• For an individual making >$210,000 /year they pay $3,700/year

• For a couple making >$430,000/year they pay $3,700/year

This is an area of tremendous political discussion and interest. Currently there is no difference in Medicare Part B premiums for multimillionaires and individuals making $210,000/year. Given the economic burden associated with Medicare several groups are advocating that this payment system be reconsidered.

Speakers Notes Slide #14:

NOTE TO SPEAKERS: Speakers should modify this slide to include the major programs that are present in your community. If there is a high penetrance of HMOs you should consider adding in additional slides in this section.

• Medi-Gap Insurances and Health Maintenance Organizations (HMOs), Managed Care Organizations, Care Maintenance Organizations (CMOS) are the complex array of insurance policies/programs that cover some of the “gap” between what Medicare covers and the cost of services. Additionally the organizations serve as “gate-keepers” to attempt to streamline services and contain costs.

• It is outside the scope of this lecture to cover this broad array of services. We are only going to be discussing what is covered in straight Medicare without supplemental insurances or managed care programs.

Speakers Notes Slide #15:

NOTE TO SPEAKERS: Speakers should ask the learners what they think are covered with by straight Medicare for office visits, laboratory tests and diagnostic tests. After the group has responded the speaker should review the answers.

Medicare Part B:

• Medicare only covers 80% of office visits. The patient is responsible for a 20% co-pay. However, if a patient has a managed care plan many have a standard co-pay of between $10-50 for a routine office visits.

• Lab tests are FULLY covered by Medicare. This is likely why providers don’t know the individual costs of a test. E.g. providers don’t know the cost of a TSH versus a Hematocrit.

• Diagnostic tests such as CT scans or MRIs are only partially covered. Additionally many HMOs require approval to obtain the more expensive testing except in emergency situations.

Speakers Notes Slide #16:

NOTE TO SPEAKERS: Speakers should ask the learners what they think are covered by straight Medicare for transportation, hearing aids, eye glasses and then review.

• Medicare coverage for transportation is for emergencies only. An ambulance to the ED will be covered but routine transportation for doctor’s appointments is not covered. Also, discharge from an acute care hospital to a SNF is covered.

• Hearing aids are not covered.

• Eyeglasses are only covered in the post-operative setting and then only 80 %.

• Outpatient dentistry is not covered by Medicare.

Speakers Notes Slide #17:

NOTE TO SPEAKERS: Speakers should ask the learners what they think are covered by straight Medicare for Long Term Home Attendant (HA) and short term HA.

• Long term HA are not covered at all by Medicare. This critically important fact is frequently not appreciated by medical trainees since historically the patients your clinics are dual eligible with Medicare and Medicaid.

• Short term HA are covered by Medicare if there is a “skilled need” for up to 20 hrs/wk. We will return to this topic later and elaborate on the definition of a “skilled need.”

•

Speakers Notes Slide #18: N/A

Speakers Notes Slide #19:

Sub-Acute Rehabilitation (SAR) is covered by Medicare.

• up to 20 days-100 %

• 21-100 days-$141.50/day

• >100 days-no coverage

• As you are aware many of your older patients are discharged from the hospital to SAR. This is a covered expense and allows additional services before the patient returns home with very limited options for services.

• The coverage is per hospital admission. If readmitted with new diagnosis you can then “reset the clock.” There are “life time years” but this does not come up as a problem on a routine basis with older adults.

Speakers Notes Slide #20:

• A major point that needs to be clear is that in addition to Medicare not covering a long term HA. Medicare does not provide for LTC.

Speakers Notes Slide #21:

Hospice is a MEDICARE benefit. You can also have a Hospice benefit with other insurance plans. This lecture is not designed to cover this topic in depth. However Hospice is an additional Medicare program which provides a broad array of services.

• Eligibility requires that a patient be terminally ill with an expected prognosis of < 6 months.

• Patient choose to receive care from a hospice

• Hospice covers essentially all costs of the terminal illness including medications, transportation, home aids (20 hrs/week), inpatient respite care, and bereavement services.

Speakers Notes Slide #22:

Medicare Part D

Prescription Plan was mandated in 2006. It is complex to understand and there are many nuances which vary according to the state policies.

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.

Speakers Notes Slide #23:

NOTE TO SPEAKERS: Since Medicaid is a state program slides should be updated with local information.

• State program based on poverty level

• Benefits vary dramatically from state to state

• Two categories of eligibility:

➢ Age > 65 or < 18 years old

➢ On Public Assistance

Speakers Notes Slide #24:

Medicaid Eligibility-NY

• Resource limit:

o Individual: $13,800

o Couple: $20,100

• Exemptions:

o $1,500 per person for burial fund, home, car, health insurance premiums.

o Can continue in your own home but home is an asset.

o 5 year “look-back” for assets donated to family/friends.

Speakers Notes Slide #25:

Some states have a “spousal allowance” so that a community spouse is not impoverished when their spouse is institutionalized.

Speakers Notes Slide #26:

In NY Medicaid covers 100% of hospitalization, office visits, lab and diagnostic tests

Speakers Notes Slide #27:

• In NY Medicaid covers medications after a $1-3 co-pay. Medicaid covers 100% of transportation, Hearing aids for 1 ear, eyeglasses and dental.

Speakers Notes Slide #28:

In NY Medicaid covers 100% of long term and short term HA. 100% of day programs, SAR and NH.

Nationally, NH reimbursement in the United States:

• 8 percent Medicare

• 68 percent Medicaid

• 23 percent private pay

Speakers Notes Slide #29:

Let’s now return to our case. To review:

In 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.

– She is not Medicaid eligible because of her pension and savings.

Speakers Notes Slide #30:

NOTE TO SPEAKERS: Ask learners about options for care. Answers usually include-ED visit, Hospitalization. This is an opportunity to discuss referral to a Home Health Agency which is a Medicare benefit.

Our patient 8 years later:

• She is now 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.

• In this case pt was successfully referred to a Home Health Agency.

Speakers Notes Slide #31:

• Let me review what is involved with a community referral to a Home Health Agency. This is NOT the form which you’re required to fill out for patients with Medicaid who have Home Attendants.

• Rather this is a Medicare covered benefit for all patients over the age of 65. The referral requires a physician’s order for a “skilled need” in Nursing, Physical or Speech Therapy.

• Once a referral is initiated, the entire team can become involved for evaluation. Even if there is not a skilled need in their domain. Diagnosis which quality as a skilled need for referral include:

• Gait disorder, falls, medication compliance, wound care, patient education.

• If you’re not certain what qualifies as a skilled need under Medicare guidelines, the intake nurse at the Home Health Agency can guide you.

• Our patient has multiple skilled needs including: medication compliance, fall assessment and wound care.

Speakers Notes Slide #32:

• Home Health Agency can address some of the following issues:

• Nursing :

➢ wound care, medication management, disease specific assessment

• Physical Therapy:

➢ Gait and balance training, focused PT for specific musculoskeletal disorders

➢ Adaptive equipment: grab bars, tub seat, raised toilet seat

• Speech therapy:

➢ Swallowing assessment

• Social Work:

➢ Financial assessment, entitlements assessment, transportation,

• Short term home attendant:

➢ 4 hrs/day for 5 days a week to help with personal care for 1 month

Speakers Notes Slide #33:

• 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.

Speakers Notes Slide #34:

NOTE TO SPEAKERS: Community services vary widely. This slide should be modified.

There are a variety of community services available which may include

• 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

• Medicaid may cover under special circumstances

Speakers Notes Slide #35:

NOTE TO SPEAKERS: Community services vary widely. This slide should be modified.

• There are also specialized community services such as

• Services for visually impaired

• Library of Congress: Books on Tape

• The Lighthouse

• Jewish Guild for the Blind

Speakers Notes Slide #36:

• Ms. R’s weight stabilized with the addition of Meals on Wheels.

• She started using Access-A–Ride rather than the bus.

• She purchased a PERS.

Speakers Notes Slide #37:

• 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.

Speakers Notes Slide #38:

Options:

• Pay for help privately

• Spend down for Medicaid eligibility

Speakers Notes Slide #39:

NOTE TO SPEAKERS: The cost of private pay help varies widely. This slide should be modified.

The cost of Private Pay Help

Agency fees for 24 hr. care:

• $230/day = $6,900/month which comes to $82,800/year

• She will deplete her savings in less than 3 years and be Medicaid eligible with a monthly “spend-down.”

Speakers Notes Slide #40:

NOTE TO SPEAKERS: Community services vary widely. This slide should be modified.

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

• Respite Care

Speakers Notes Slide #41:

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.

Speakers Notes Slide #42:

• 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.

• Update: She died peacefully at home in 2011 at the age of 92.

Speakers Notes Slide #43:

• 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

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