Does My Medicare Cover This?

The most frequently asked question when we sit down with a family and begin discussing the need for assisted living - what will be covered by Medicare?  Family members are often shocked and disappointed when the reality that assisted living can and will cost the family an additional $30-60,000 annually. Families may understand Medicare will pay for skilled nursing care, but they too often misunderstand that Medicare covers the time in a skilled nursing facility if and when there is a specialized need defined by Medicare and they only receive up to 100 days per year as long as the person requires skilled nursing and rehabilitation services.  Medicare is our government health insurance plans that covers doctors, hospitals, labs and diagnostics plus rehabilitative services.  When assistance with bathing, dressing, medications, meals, toileting, (activities of daily living) is needed, assisted living fills in the gap.  These tasks can be demanding and stressful, but are considered custodial in nature and not skilled.  Therefore, the financial responsibility comes back to the individual or family when the primary issues are considered custodial. 
 
There could be help from another government program known as Medicaid that does provide benefits for people who have both a demonstrated financial and medical need to offset the costs of long term care when the need is primarily custodial.  There are some strict qualification requirements, and in Arizona, we refer to that program as ALTCS (Arizona Long Term Care System).  Families and individuals can apply for that program separately by calling (602) 417-6600 or going to www.azahcccs.gov for more information.
 
There are two significant Medicare benefits that families ask us about all the time and we want to highlight them here.  The two benefits are home health (not to be confused with home care!) and hospice.  These two services are different and have distinct purposes, but either benefit can be accessed at home or while in assisted living and triggered when a physician prescribes them.  Because Medicare is the payer, a frequent review of services will occur for appropriateness and effectiveness.
 
Home health provides skilled nursing and home health aides, social workers plus rehab services conducted by a physical, occupational or speech therapist under the prescribing physician’s direction for a limited amount of time if that person is considered homebound.  Home health staff comes to the home or assisted living for a specified number of skilled visits (usually 30-60 minutes in length) for the duration of the treatment plan. Home care is private duty caregivers and companions that a family would pay for privately for extended periods of time during the day or week. Medicare does not cover home care.
 
Hospice care is for people who are nearing the end of life. They must have a qualifying diagnosis that a physician writes a prescription for hospice services. This service includes care provided by nursing staff, CNA’s, MSW and clergy to assist the individual and family with the issues surrounding the end of life.  In most cases, hospice care is mobile, and the team comes to a person’s home or assisted living facility.  There are times when the individual may be considered for an inpatient stay or respite stay.  Each hospice company handles that issue a bit differently; most receive their end of life care in the privacy of their home or assisted living home.  Home health and hospice are usually mutually exclusive- meaning it is either one or the other.  It’s rare to have them concurrently involved with an individual.