Medicare Information for Caregivers

As caregivers help family members or friends make health care decisions, Medicare can be an important factor in many of those decisions. It is important to understand the role Medicare can play in planning for medical care, managing chronic illness and hospitalization, and paying for medical expenses.

Planning for Medical Care

If you find that an older relative or friend needs your help to deal with a medical condition, there are a number of steps you can take to help that person plan for medical care. Begin by talking with the person and other family members about medical and prescription drug needs, as well as about who should have permission to act on the person's behalf.

Find out what kind of health coverage the person already has. If the person has Medicare, find out which parts: Medicare Part A (hospital insurance), Part B (medical insurance), or Part D (prescription drug coverage). Also, find out whether the person is in Original Medicare, in a Medicare Advantage Plan (like an HMO or PPO), or in any other type of Medicare health plan. This information is on the person's Medicare card.

If the Medicare card for the person you care for is not available for you to look at, you can either call Medicare together, or the person can complete an authorization form to allow you to get Medicare information released to you. To get an authorization form, call Medicare at 1-800-Medicare (1-800-633-4227). TTY users should call 1-877-486-2048. If the person does not currently have Medicare, find out when he or she will be eligible to enroll.

It is also important to find out if the person has other health coverage in addition to Medicare, such as a health plan with a former employer, Medicaid, or other insurance that can help pay for health care needs. If the person is enrolled in Original Medicare, also find out if he or she has a Medicare Supplement (Medicare Supplement) policy.

As you work together to plan for medical care, it will be helpful to have the following information about the person.

• Social Security number
• Medicare number and Medicare plan
• other insurance plans and policy numbers, including long-term care insurance
• contact information for health care professionals, including doctors, specialists, nurses, pharmacists
• current list of prescription and over-the-counter drugs, herbal remedies, and their dosages
• current health conditions, treatments, and symptoms
• history of any past health problems
• any allergies or food restrictions
• emergency contacts, close friends, neighbors, clergy, housing manager
• where to find financial and legal information, including the person's living will and medical power of attorney

When you have a Medicare concern that needs to be discussed, a good resource is the State Health Insurance Assistance Program, or SHIP. SHIP gives free health insurance counseling and guidance to people with Medicare -- or to family and friends, like you, who have authorization to help someone with Medicare questions. (In some states, SHIP is known as SHIBA or SHINE.)

Illness and Hospitalization

Facing a chronic health condition or surgery will raise questions and increase concerns for the person you care for. Talk with this person about his or her condition and treatment, and about what the doctor said during visits. Going over the facts may relieve some concerns and give a more realistic picture of the situation. Having your support is important.

When a person's doctor recommends surgery or a major medical test, encourage the patient to get a second opinion -- even a third opinion. Getting a third opinion is beneficial when the first and second opinions are different. Seeing a second or third doctor can provide information that helps patients decide on the best course of action for their health.

Medicare covers second and third opinions for non-emergency surgery. Original Medicare also helps pay for certain medical tests that may be required to get additional doctors' opinions. Examples of non-emergency surgery are a gall bladder procedure, hysterectomy, hernia repair, or cataract operation. Some Medicare Advantage Plans may require the primary care doctor to give a written referral to another doctor for a second or third opinion.

Always ask if a doctor or supplier accepts "assignment." Assignment is an agreement between Medicare doctors, health care providers, and suppliers to accept the Medicare- approved amount as payment in full. If a doctor or supplier does accept assignment, Medicare will pay 80 percent of the cost, and the patient pays the rest.

If a person needs to be hospitalized, Medicare will cover inpatient hospital care when all of the following are true.

• A doctor says the person with Medicare needs inpatient hospital care to treat an injury or illness.
• The person with Medicare needs the kind of care that can be given only in a hospital.
• The hospital has an agreement with Medicare.
• The Utilization Review Committee of the hospital approves the stay while the person with Medicare is in the hospital.

If a person is hospitalized, Medicare helps pay for certain types of services:

• Care - general nursing
• Room - semiprivate room
• Hospital services - meals, most services and supplies

If a person is hospitalized, Medicare does NOT pay for the following services:

• Care - private-duty nursing
• Room - private room (unless medically necessary)
• Hospital services - television and telephone

For more information about Medicare Part A, visit www.medicare.gov and view or print a copy of "Your Medicare Benefits " and "Medicare & You ."

Prescription Drug Coverage

Medicare offers prescription drug coverage for everyone with Medicare. This coverage is called "Part D." To get Medicare drug coverage, a person must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. If a person wants Medicare drug coverage, he or she needs to choose a plan that works with their health coverage.

There are generally two ways to get Medicare prescription drug coverage: join a Medicare Prescription Drug Plan (PDP) or a Medicare Advantage (MA) Plan. A person can also enroll in an employer or union-sponsored plan. To join a Medicare Prescription Drug Plan, a person must have Medicare Part A and/or Part B. To join a Medicare Advantage Plan (like an HMO or PPO), a person must have Part A and Part B. The person must also live in the service area of the Medicare drug plan he or she wants to join.

Medicare Prescription Drug Plans add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.

Medicare Advantage (MA) Plans, like a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO), or another Medicare health plan each include prescription drug coverage. People get all of their Medicare coverage, including prescription drugs, through these plans.

If a person has prescription drug coverage from a former or current employer or union, contact the plan's benefits administrator before making any changes to the drug coverage. Joining a Medicare drug plan could change how the person's employer or union coverage works, both for the person and any dependents covered by the plan. Also, if a person has prescription drug coverage from TRICARE, the Department of Veterans Affairs (VA), or the Federal Employee Health Benefits Program (FEHBP), contact the plan's benefits administrator or insurer before making any changes. In most cases, it will be to the person's advantage to keep the current coverage. However, in some cases, adding Medicare prescription drug coverage can provide extra coverage and savings, especially if the person qualifies for extra help.

Each Medicare drug plan has a list of prescription drugs that it covers, called a formulary, or drug list. Plans may cover both generic and brand-name prescription drugs. Most prescription drugs used by people with Medicare will be on a plan's drug list. To find out which drugs a plan covers, contact the plan or visit the plan's website. All Medicare drug plans must make sure that the people in their plan can get medically-necessary drugs to treat their conditions.

Medicare drug plans may have rules about prior authorization, quantity limits, and step therapy. Prior authorization means that the person and/or the doctor must contact the plan before certain prescriptions can be filled. The doctor may need to show that the drug is medically necessary for it to be covered. Quantity limits are limits on how many pills a person can get at a time. Step therapy is a type of prior authorization in which a person must try one or more similar, lower cost drugs before the plan will cover the drug the doctor prescribed.

If the doctor believes that one of these coverage rules should be waived, the person can ask for an exception. (If someone receives an exception, it means that a drug coverage rule does not apply in a particular case.)

Having a variety of plans to choose from gives people with Medicare the chance to pick a plan that meets their unique needs. To help the person choose a plan that will provide the right coverage at the best price possible, you can:

• visit www.medicare.gov to view or print copies of "Your Guide to Medicare Prescription Drug Coverage"
• call 1-800-Medicare (1-800-633-4227). TTY users should call 1-800-325-0778
• call the State Health Insurance Assistance Program (SHIP) in your state for personalized help

You can also find information in the "Medicare & You" handbook which is mailed out to Medicare enrollees in the Fall. It includes detailed information about Medicare drug plans, including which plans are available in your area. Contact us for the plans you are interested in for more details: 1-866-646-7654

Continuing Care Options

A serious illness or injury can create a need for ongoing care. With the right kind of support, some people can continue to lead independent, productive lives at home. Others may need full-time care outside the home. And for those who cannot recover, end-of-life care may be the answer. Medicare can cover costs for some continuing care needs.

Home Health Care

Home health care is short-term skilled care at home after hospitalization or for the treatment of an illness or injury. Home health agencies provide home care services, including skilled nursing care, physical therapy, occupational therapy, speech therapy, medical social work, and care by home health aides.

Home health services may also include durable medical equipment, such as wheelchairs, hospital beds, oxygen, and walkers, and medical supplies for use at home.

If a patient has Medicare, he or she can use the home health benefit if all of the following conditions are met.

1. The doctor must decide that the patient needs medical care at home, and makes a plan for this care.
2. The patient must need one or more of the following services.
   • intermittent skilled nursing care
   • physical therapy
   • speech-language pathology
   • continued occupational therapy
3. The home health agency selected must be approved by the Medicare Program (Medicare-certified).
4. The patient must be homebound or normally unable to leave home unassisted. To be homebound means that leaving home takes considerable effort. Patients may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to attend religious services. A patient can still get home health care if he or she attends adult day care.

To find out if a patient is eligible for Medicare's home health care services, call the Regional Home Health Intermediary (RHHI). A RHHI is a private company that contracts with Medicare to pay bills and check on the quality of home health care. To contact a RHHI, call 1-800-Medicare (1-800-633-4227) or visit www.medicare.gov. TTY users should call 1-877-486-2048.

If the doctor decides the patient needs home health care, you can choose an agency from the participating Medicare-certified home health agencies that serve the area. To find an agency, ask the doctor or hospital discharge planner, use a senior community referral service or agency, or look in the telephone directory in the Yellow Pages under "home care" or "home health care."

Home health agencies are certified to make sure they meet certain Federal health and safety requirements. The choice of a home health agency should be honored by the patient's doctor, hospital discharge planner, or other referring agency.

Here are questions to ask when considering a home health agency.

• Is the agency Medicare-approved?
• How long has the agency served the community?
• Does this agency provide the services my relative or friend needs?
• How are emergencies handled?
• Is the staff on duty around the clock?
• How much do services and supplies cost?
• Will agency staff be in regular contact with the doctor?

You can use Medicare's "Home Health Compare" tool to compare home health agencies in your area.

There are times when a person's needs extend beyond the intermittent skilled care provided through Medicare. Community-based services across the country support independent living and are designed to promote the health, well being, and independence of older adults. These services can also supplement the supportive activities of family caregivers.

Often, community-based senior citizens' services offer companionship visits, help around the house, meal programs, caregiver respite, adult day care services, transportation, and more. These support services may be funded by state and county programs or offered by church or volunteer groups.

Nursing Homes and Housing Options

Serious and chronic illness may create a need for full-time care outside the home. It is a decision you and the person you care for should discuss with the doctor as well as other family members.

There are several categories of care available in most communities, ranging from daytime activities to full-time care. These include independent living facilities, assisted living facilities, continuing care retirement communities (CCRCs), adult day care, custodial care, skilled nursing facilities, and nursing homes. A description of each of these categories of care follows.

Independent Living Facilities: These are settings designed for independent living while offering meals, social and recreational activities, and other support.

Assisted Living Facilities: These are residential homes offering a range of services that usually include activities of daily living, supervision, and medication management.

Continuing Care Retirement Communities (CCRC): A CCRC is a housing community that provides different levels of care based on residents' needs.

Adult Day Care: Adult day care includes daily, structured activities and health-related and rehabilitation services for the elderly who need a protective environment. Care is provided during the day and the individual returns home for the evening.

Custodial Care: Custodial care provides assistance with daily activities such as bathing, eating, and dressing.

Skilled Nursing Facilities: These are facilities with 24-hour supervision and medical and rehabilitative services for patients requiring a high level of care. Medicare covers skilled nursing care after a 3-day qualifying hospital stay. Skilled care is health care given when the person needs skilled nursing or rehabilitation staff to manage, observe, and evaluate his or her care. Examples of skilled care include changing sterile dressings and physical therapy. Care that can be given by non-professional staff isn't considered skilled care.

If you are considering nursing home care, you can begin your search at http://www.medicare.gov. You can find many links that can help you gather information about Medicare- and Medicaid-certified nursing facilities and long-term care options in your state. You also can compare the quality of nursing homes in your area. To look at or print a copy of the booklet "Medicare Coverage of Skilled Nursing Facility Care," go to "Search Tools" and select "Find a Medicare Publication." You can also call 1-800-Medicare (1-800-633-4227) to find out if a free copy can be mailed to you. TTY users should call 1-877-486-2048.

Nursing Homes: Nursing Homes serve as permanent residences for people who are too frail or sick to live at home because of physical, emotional, or mental problems. Nursing homes provide a wide range of personal care and health services, including helping people with dressing, bathing, and using the bathroom. Nursing home residents usually require daily assistance.

Here are some questions to ask when considering choosing a nursing home. You may want to make surprise visits at different times of the day to verify conditions.

• Is the nursing home Medicare- or Medicaid-certified?
• Does the nursing home have the level of care needed (such as skilled or custodial care) and is a bed available?
• Does the nursing home have special services if needed in a separate unit (such as a ventilator or rehabilitation) and is a bed available?
• Are residents clean, well groomed, and appropriately dressed for the season or time of day?
• Is the nursing home free from strong, unpleasant odors?
• Does the nursing home appear to be clean and well kept?
• Does the nursing home conduct staff background checks?
• Does the nursing home staff interact warmly and respectfully with home residents?
• Does the nursing home meet cultural, religious, and language needs?
• Are the nursing home and the current administrator licensed?

Nursing home care can be very expensive. Medicare generally doesn't cover nursing home care. There are many ways people can pay for nursing home care. For example, they can use their money, they may be able to get help from their state, or they may use long-term care insurance.

Nursing home care isn't covered by many types of health insurance. Most people who enter nursing homes begin by paying for their care out of their own pocket. As they use up their resources over a period of time, they may eventually become eligible for Medicaid.

Medicaid is a state and Federal program that will pay most nursing home costs for people with limited income and resources. Eligibility varies by state. Medicaid pays for care for about 7 out of every 10 nursing home residents. Medicaid will pay for nursing home care only when provided in a Medicaid-certified facility. For information about Medicaid eligibility, call your state Medical Assistance (Medicaid) Office.

If you have questions about Medicaid, you can call your State Medical Assistance (Medicaid) office for more information. Visit www.medicare.gov on the web for Find Helpful Phone Numbers and Websites. Or, call 1-800-Medicare (1-800-633-4227) to get the telephone number. TTY users should call 1-877-486-2048.

Hospice Care

Hospice care is a special way of caring for people who are terminally ill (dying) and helping their families cope. Hospice care includes treatment to relieve symptoms and keep the individual comfortable. The goal is to provide end-of-life care, not to cure the illness. Medical care, nursing care, social services, drugs for the terminal and related conditions, durable medical equipment, and other types of items and services can be a part of hospice care.

Most hospice patients get hospice care in the comfort of their home and with their families. Depending on the patient's condition, hospice care also may be given in a Medicare-approved hospice facility, hospital, or nursing home.

Medicare's hospice benefit provides for support and comfort to patients who are dying, including services not usually paid for by Medicare. Hospice volunteers are available to do household chores, provide companionship, allow the caregiver time off to do tasks outside of the house, and offer support to the patient and family. Medicare also pays for inpatient respite care (short term care for hospice patients) so that the usual caregiver can rest.

To be eligible for hospice care, the patient must have Medicare Part A (hospital insurance) and

• the doctor and hospice medical director must certify that the patient is terminally ill and has probably six months or less to live
• the patient must sign a statement choosing hospice care instead of routine Medicare-covered benefits for their terminal illness
• the patient must receive care from a Medicare-approved hospice program

Medicare hospice benefits do not include treatment to cure terminal illness. If the patient's health improves or the illness goes into remission, he or she always has the right to stop getting hospice care and go back to the regular Medicare health plan. A hospice patient will continue to have Medicare benefits to help pay for treatment of conditions unrelated to the terminal illness.

Here are questions you may wish to consider when selecting hospice care providers.

• Does the hospice provider train caregivers to care for the patient at home?
• How will the patient's doctor work with the doctor in the hospice program?
• What is the patient-to-staff ratio?
• Does the hospice staff meet regularly with the patient and family to discuss care?
• How does the hospice staff respond to after-hour emergencies?
• What measures are in place to ensure hospice care quality?
• What services do hospice volunteers offer? Are they trained?
• Is the hospice program certified and licensed by the state or federal government?

To find a hospice program, call 1-800-Medicare (1-800-633-4227) or your State Hospice Organization in the blue pages of your telephone book. (TTY users should call 1-877-486-2048.) You may also call your Regional Home Health Intermediary (RHHI) for more information about Medicare hospice benefits. An RHHI is a private company that contracts with Medicare to pay bills and check on the quality of hospice and home health care. Medicare requires the hospice agency and hospice team you choose to provide care.

To get local telephone numbers for your RHHI or State Hospice Organization, call 1-800-Medicare (1-800-633-4227). TTY users should call 1-877-486-2048.