Long-Term Care Coverage
Understanding Long Term Care
Many people do not know about or understand all the long term care options that are available. The following are brief descriptions of the major types of long term care, the kinds of service you may need, the ways of paying for long term care and how to find the best services and facilities:
Home care can be given in your own home by family members, friends, volunteers, and/or paid professionals. This type of care can range from help with shopping to nursing care. Another type of care that can be given at home is hospice care for terminally ill people.
Community services are support services that can include adult day care, meal programs, senior centers, transportation, and other services. These programs can help people who are cared for at home by their families. For example, adult day care services provide a variety of health, social, and related support services in a protective setting during the day. This can help adults with impairments (such as Alzheimer’s disease) continue to live in the community. And it can give family or friend caregivers a needed “break.”
Supportive housing programs offer low-cost housing to older people with low to moderate incomes. The Federal Department of Housing and Urban Development (HUD) and State or local governments often develop such housing programs. A number of these facilities offer help with meals and tasks such as housekeeping, shopping, and laundry. Residents generally live in their own apartments.
Assisted living provides 24-hour supervision, assistance, meals, and health care services in a home-like setting. Services include help with eating, bathing, dressing, toileting, taking medicine, transportation, laundry, and housekeeping. Social and recreational activities also are provided.
Continuing care retirement communities (CCRCs) provide a full range of services and care based on what each resident’s needs over time. Care usually is provided in one of three main stages: independent living, assisted living, and skilled nursing.
Nursing homes offer care to people who cannot be cared for at home or in the community. They provide skilled nursing care, rehabilitation services, meals, activities, help with daily living, and supervision. Many nursing homes also offer temporary or periodic care. This can be instead of hospital care, after hospital care, or to give family or friend caregivers some time off (“respite care”).
Intermediate Care Facilities for the Mentally Retarded: This is another type of long term care for the mentally retarded that takes place in home-like settings. They provide a wide variety of services to mentally retarded and developmentally disabled people from youth to old age. Services include treatment to help residents become as independent as possible, as well as health care services.
Learn More: You can learn about long term care options in your area by contacting:
- The Eldercare Locator (1-800-677-1116, weekdays, 9.00 a.m. to 8.00 p.m., EST). This service can refer you to your Area Agency on Aging.
- Area Agencies on Aging provide information on a wide variety of community-based services. Examples are meals, home care, adult day care, transportation, housing, home repair, and legal services.
- Your State or local Long Term Care Ombudsman (call the Eldercare Locator,1-800-677-1116, weekdays, 9.00 a.m. to 8.00 p.m. for the number). Ombudsmen visit nursing homes and other long term care facilities to check on and resolve complaints, protect residents’ rights, and give emotional support to lonely older people. A call to your area Ombudsman can give you information on: the most recent State survey (inspection) report of the facility; the number of outstanding complaints; the number and nature of complaints lodged in the last year; and the results of recent complaint investigations.
- “Nursing Home Compare Web Site” www.medicare.gov/Nursing/Overview.asp – a Web site created by the Health Care Financing Administration, which runs Medicare and Medicaid. This site helps you locate nursing homes in your area. It also has inspection records for nursing homes that receive Medicare or Medicaid funds.
- Hospital discharge planners.
- Social workers (some can be “case managers” or “care managers,” who can help you coordinate long term care services).
- Doctors and other health care professionals.
- Local nursing facilities.
- Volunteer groups that work with older people.
- Clergy or religious groups.
- Family and friends.
What Kind of Services Do I Need?
The first question to ask yourself when trying to decide what type of services are needed for you or for your loved ones is “what kind of services do I need?”. To help find out what kind of services you or a loved one need, check the items below that apply. Keep in mind that these needs may change over time.
Help With Daily Activities
[_] Preparing meals
[_] Laundry and other housework
[_] Home maintenance
[_] Paying bills and other money matters
[_] Going to the bathroom
[_] Remembering to take medicines
[_] Other _______________________
[_] Other _______________________
Health Care Needs (as recommended by a doctor or other health care provider)
[_] Physical therapy
[_] Speech therapy
[_] Occupational therapy
[_] Medical nutritional therapy
[_] Care for pressure ulcers or other wounds
[_] Alzheimer’s disease care
[_] Health monitoring (for diabetes, for example)
[_] Pain management
[_] Nursing care services
[_] Other medical services provided by a doctor or other clinician
[_] Other _______________________
How Will I Pay for these Services?
The second question to ask yourself is “How will I pay for these Services?” Long-term care can be very expensive. In general, health plans and programs do not routinely cover long term care at home or in nursing homes. Here is some general information about long term care coverage:
- Medicare is the Federal health insurance program for people age 65 and older and for some disabled younger people. Medicare generally does not pay for long term help with daily activities. Medicare pays for very limited skilled nursing home care after a hospital stay. If you need skilled care in your home for the treatment of an illness or injury, and you meet certain conditions, Medicare will pay for some of the costs of nursing care, home health aide services, and different types of therapy.
- Medicaid is a Federal-State program that pays for health services and long term care for low- income people of any age. The exact rules for who is covered vary by State. Medicaid covers nursing home care for people who are eligible. In some States, Medicaid also pays for some home and community services.
- Private Insurance. If you need long term care now, it is probably too late to be purchasing long term care insurance. In eight out of 10 couples aged 65 and older, at least one spouse will enter a nursing home (AHIP, “A Guide to Long Term Care Insurance”, 2004). So, if it is not too late, you should be seriously considering long term care insurance. Insurance companies are becoming more and more aware of the growing need for long term care. Most insurance companies today offer long term care insurance policies. These policies may cover services such as care at home, in adult day care, in assisted living facilities, and in nursing homes. But plans vary widely. If you have such a policy, ask your insurer what it covers. If you think you may need long term care insurance, start shopping while you are relatively young and healthy, and shop carefully.
- Personal Resources. You may need to use resources such as savings or life insurance to pay for long term care. Most people who enter nursing homes begin by paying out of their own pockets. As their personal resources are spent, many people who stay in nursing homes for a long time eventually become eligible for Medicaid.
Other Resources to Find Help. Your State Health Insurance Program (SHIP) can give you general information about Medicare, Medicaid, managed care plans, and the types of health insurance that can supplement Medicare, including Medigap and long term care insurance. Counselors also can help you with questions about your medical bills, insurance claims, and related matters. These services are free. To find the phone number of the SHIP office in your State, call the Medicare Hotline at 1-800-638-6833. Or, look at the consumer Web site for Medicare services, www.medicare.gov.
How Can I Choose the Best Quality Services and Facilities?
The third question to ask yourself is “How do I find and choose the Best Quality Services and Facilities?” Here are some tips for choosing the kinds of long term care people most often use: home care (including home health care) and nursing homes.
- In many States, home care agencies must be licensed. Check with your State health department to see if your State requires it. If so, be wary if an agency is not licensed.
- Ask if the agency is certified by Medicare. Medicare inspects home health care agencies to assure they meet certain Federal health and safety requirements. Medicare will pay for services only if the agency is Medicare-approved and if the services are covered by Medicare.
- If the home health care agency is certified by Medicare, you can review its survey report. Call the Medicare Hotline at 1-800-638-6833 and ask to be referred to the Home Health Hotline for your State. You can request a copy of the report from that hotline.
- Find out if the agency has been accredited (awarded a “seal of approval”) by a group such as the Joint Commission on Accreditation of Healthcare Organizations (630-792-5800); www.jcaho.org) or the Community Health Accreditation Program (1-800-669-9656; www.chapinc.org)
- Call your State or local consumer affairs office to see if any complaints have been filed against a home care agency. Also ask about the outcome of any complaint investigations.
- Whether you work with an agency or hire someone yourself, carefully check the backgrounds of the people who will be coming into your home. Ask for references who have worked with the agency or person. Call them, and ask about their experiences. Would they use the agency or person again?
- Does the home care worker have the necessary skills and training for your needs? Ask to see training certificates. Make sure the worker knows how to safely assist and care for patients.
- Does the agency have supervisors who check on the quality of care its workers provide?
- How does the agency follow up on and resolve complaints?
Nursing Home Care
- All nursing homes that participate in Medicare or Medicaid are visited about once a year by a team of trained inspectors. They check the home and the care provided and prepare a survey report. You have a right to review the report, which must be posted in the nursing home. Speak to the nursing home administrator to learn more about any problems that appear on the report. Ask if the problems have been corrected.
- Call your State or local long term care Ombudsman. Ombudsmen visit nursing homes on a regular basis and know about each nursing home in their area. You can ask about the latest survey report and about complaints that have been filed. You can also ask what to look for when visiting local nursing homes.
- Compare the inspection records of your top choices by visiting the “Nursing Home Compare” Web site: www.medicare.gov/NHCompare/Home.asp
- Some nursing homes have been accredited by a national group such as the Joint Commission on Accreditation of Healthcare Organizations (630-792-5800). It may be helpful to find out if the home participates in the voluntary process and to learn the results.