About Medicare Long Term Care
by Thomas Day

Medicare Nursing Home Coverage
Medicare Home Care Coverage
Social Health Maintenance Organizations (S/HMO)
Program Of All Inclusive Care For The Elderly (PACE)


Medicare Nursing Home Coverage
Medicare is the vision and campaign promise of President John F. Kennedy to provide universal medical insurance to all aged Americans. His untimely death did not allow him to fulfill his promise, but President Lyndon Johnson was able to win passage of the plan in the form of amendments to the Social Security Act. Passed in 1965, Title VIII of the amendment established Medicare and Title IX established Medicaid.

Medicare Part A & B is now the health insurance plan for all eligible individuals age 65 and older and certain younger disabled persons.. Because of its universal availability almost everyone over age 65 in this country is covered by Medicare. There are about 40 million Medicare beneficiaries nationwide.

Medicare will pay for 20 days of a skilled nursing care facility at full cost and the difference between the amount above $114 (2005) per day and the actual cost for another 80 days. Private Medicare supplement insurance usually pays the 80 days of $114 per day if a person carries this insurance and the right policy form. However, Medicare often stops paying before reaching the full 100 days. When Medicare stops, so does the supplement coverage. The average paid Medicare nursing home stay was 23 days in 1997, only 1/5 of the allowable time. Nationwide, Medicare paid 12% of nursing home receipts in 1998.

To qualify for Medicare nursing home coverage, the individual must spend at least 3 full days in a hospital and must have a skilled nursing need and have a doctor order it. The transfer from a hospital must occur within a certain time period.

There is a misconception that Medicare automatically covers up to 100 days of most nursing home stays. . Even though a large number of nursing home admissions come from hospitals, not all of these receive Medicare. Many are younger than 65 and not on Medicare. For those over 65, a hospital stay resulting in nursing home care does not automatically qualify for Medicare coverage. The stay may have been less than 3 full days or there may not be a skilled need. And as has already been pointed out, even if a person qualifies for Medicare coverage it is likely to be much less than 100 days. The average coverage is about 20 days.

Medicare Home Care Coverage
Medicare is a principal provider of home health care and hospice care in the nation; although, there is now a growing trend for Medicaid to provide home care.

Home health care, instead of nursing care, is often used as an alternative for hospital patients recovering from hip or foot surgery, joint replacement or complications of diabetes. In addition, homebound patients not having spent time in a hospital, but suffering from congestive heart failure or other disabling conditions are sometimes covered with "episodes" at home.

Home care must be under a "plan of care" ordered by a doctor. There must be a skilled need requiring frequent visits by either a therapist, LPN or RN. Although allowed prior to 1997, blood draws are not covered. As part of the plan of care, aides may also be provided to help with bathing, dressing, transferring, toileting, incontinence or feeding. In addition, social services are often provided. The patient must be homebound, meaning it would be very difficult to leave the home during the period of recovery. Although, a recent ruling now allows Medicare home care patients to leave their home for therapy or treatment and still receive coverage. Medicare part B may also cover certain durable medical equipment for home care such as bed rails, walker, etc.

Prior to 1997, Medicare payments were very helpful in allowing long-term care recipients to stay at home and avoid institutions. But, Medicare was never intended to pay for chronic, long-term home care. A 1989 lawsuit asserting rights of homebound recipients as well as a lack of Medicare oversight allowed the system to get out of hand. Home health payments by Medicare increased an astounding 25% a year between 1990 and 1997, about 4 times the health care inflation rate.

In 1996, Congress passed the Balanced Budget Act and along with the Health Insurance Portability and Accountability Act of the same year, access to Medicare home health was restricted and the intent of only covering acute-care recovering patients was reasserted by these Acts.

In November 1997, under BBA, Medicare adopted an interim payment system based on a projected 1999 implementation of a Prospective Payment System for home care. PPS greatly restricted eligibility and reimbursements for homebound patients. Medicare home health benefits went from a high of $18.3 billion in 1997 to $9.5 billion in 1999, a drop almost in half. At the same time demand for covering more home care patients increased. After 1997, the number of home health agencies fell by a large amount almost overnight. Home health was 8.8% of Medicare's budget in 1997. In 1999 it was 4.6% of the budget. Medicare paid 35.6% of home health costs in 1998.

Under Prospective Payment, a health agency is only reimbursed per patient for each 60 day episode. This does not mean care can be less or more than 60 days since the agency can schedule visits until the prospective payment runs out. There are provisions to cut off reimbursement if the patient recovers early, or to extend payment if the condition worsens. Recent complaints from the home health industry indicate that Prospective Payment is not covering actual care given.

Medicare is not now a source of help for chronic, non-improving and homebound long-term care recipients. Recently, because of pressure from home health agencies, Congress passed legislation to restore some funding to home care.

The text below was copied from the Medicare home page of the Centers for Medicare and Medicaid Services it can be found online at:

Social Health Maintenance Organizations (S/HMO)
A Social HMO is an organization that provides the full range of Medicare benefits offered by standard HMO's plus additional services which include care coordination, prescription drug benefits, chronic care benefits covering short term nursing home care, a full range of home and community based services such as homemaker, personal care services, adult day care, respite care, and medical transportation. Other services that may be provided include eyeglasses, hearing aids, and dental benefits. These plans offer the full range of medical benefits that are offered by standard HMO's plus chronic care/ extended care services. Membership offers other health benefits that are not provided through Medicare alone or most other senior health plans.

Current S/HMO Sites
There are currently four S/HMO's participating in Medicare and each S/HMO has eligibility criteria. These S/HMO plans are located in: Portland, Oregon; Long Beach, California; Brooklyn, New York; and Las Vegas, Nevada. Listed below are the four plans and the criteria for joining each plan.

* Kaiser Permanente, Portland Oregon
The enrollee must be 65 years of age or older, must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in Kaiser Permanente's S/HMO service area. The enrollee cannot have end-stage renal disease, or reside in an institutional setting. In order to receive the long-term care benefit, an expanded care resource coordinator will visit you at home to determine if you qualify for nursing home certification based on criteria established by the State of Oregon Senior and Disabled Services. These criteria may include needing daily ongoing assistance from another person with one of the following activities of daily living: walking or transferring indoors, eating, managing medications, controlling difficult or dangerous behavior, controlling your bowels or bladder, or the need for protection and supervision because of confusion or frailty.

* SCAN, Long Beach California
The enrollee must be 65 years of age or older, must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in SCAN's service area. The enrollee cannot have end-stage renal disease. In addition, in order to receive extended home care services, members must have a Nursing Home Certificate which indicates that the members informal support system , such as a family member or care giver, is not sufficient to keep the member out of a nursing home.

* Elderplan, Brooklyn, New York
The enrollee must be 65 years of age or older, must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in Elderplan's service area. The enrollee cannot have end-stage renal disease. In order to receive chronic care benefits, the enrollee must meet state nursing home certifiable criteria.

* Health Plan of Nevada, Las Vegas, Nevada
The enrollee must be at least 65 years of age, or may under 65 if they are disabled. The enrollee must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in Health Plan of Nevada's service area. The enrollee cannot have end-stage renal disease. For the long-term care benefit, the beneficiary must meet certain criteria based on established medical, psychological, functional, and social criteria as well as needing to be medically necessary.

Your Cost
Each plan has different requirements for premiums. All plans have co-payments for certain services. To obtain cost and benefit information, please visit our Medicare Health Plan Compare tool for specific details. Before making any health plan decisions, you should contact the plan directly using the phone number listed in the site.

Program of All Inclusive Care for the Elderly (PACE)
PACE is unique. It is an optional benefit under both Medicare and Medicaid that focuses entirely on older people, who are frail enough to meet their State's standards for nursing home care. It features comprehensive medical and social services that can be provided at an adult day health center, home, and/or inpatient facilities. For most patients, the comprehensive service package permits them to continue living at home while receiving services, rather than be institutionalized. A team of doctors, nurses and other health professionals assess participant needs, develop care plans, and deliver all services which are integrated into a complete health care plan. PACE is available only in States which have chosen to offer PACE under Medicaid.

Eligible individuals who wish to participate must voluntarily enroll. PACE enrollees also must:

* Be at least 55 years of age.

* Live in the PACE service area.

* Be screened by a team of doctors, nurses, and other health professionals.

* Sign and agree to the terms of the enrollment agreements.

PACE offers and manages all of the medical, social and rehabilitative services their enrollees need to preserve or restore their independence, to remain in their homes and communities, and to maintain their quality of life. The PACE service package must include all Medicare and Medicaid services provided by that State. At a minimum, there are an additional 16 services that a PACE organization must provide, e.g., social work, drugs, nursing facility care. Minimum services that must be provided in the PACE center include primary care services, social services, restorative therapies, personal care and supportive services, nutritional counseling, recreational therapy, and meals. When an enrollee is receiving adult day care services, these services also include meals and transportation. Services are available 24 hours a day, 7 days a week, 365 days a year.

Generally, these services are provided in an adult day health center setting, but may also include in-home and other referral services that enrollees may need. This includes such services as medical specialists, laboratory and other diagnostic services, hospital and nursing home care.

An enrollee's need is determined by PACE's medical team of care providers. PACE teams include:

* Primary care physicians and nurses.

* Physical, occupational, and recreational therapists.

* Social workers.

* Personal care attendants.

* Dietitians.

* Drivers.

Generally, the PACE team has daily contact with their enrollees. This helps them to detect subtle changes in their enrollee's condition and they can react quickly to changing medical, functional, and psycho-social problems.

PACE receives a fixed monthly payment per enrollee from Medicare and Medicaid. The amounts are the same during the contract year, regardless of the services an enrollee may need.

Persons enrolled in PACE also may have to pay a monthly premium, depending on their eligibility for Medicare and Medicaid.

Current Sites
There are 25 PACE sites and each site has about 200 enrollees. Limited new sites may be added each year. Sites are available in the following states. Select a state from the list below for a list of sites available in that state and the contact phone number and address for each site.







New York



South Carolina