Discharged too soon?

An Important Message From Medicare is an information piece provided to Medicare patients during hospitalization. It is indeed important, but in the avalanche of issues and papers that are part of hospitalization, it may easily be overlooked.

This Medicare message outlines the right to appeal and the process for appealing a hospital discharge decision, when the patient or family believes the individual is not ready for discharge. Taking several important steps will allow for a review of the discharge decision, while maintaining Medicare coverage of hospital costs.

Ask for An Important Message From Medicare, which outlines the following information:

1. When facing an impending discharge that you believe is premature, you must ask the hospital (typically a social worker or hospital discharge planner) for written notice explaining the reason for discharge. This notice, the Hospital Issued Notice of Noncoverage (HINN), outlines, from the hospital's perspective, why the discharge is appropriate. The information on the HINN tells how many days the patient can stay under Medicare coverage and when the patient becomes liable for hospital costs. Do not ask for the HINN until you are upon the determined discharge date, not in advance.
2. If you still disagree with the discharge after you receive the HINN notice, you can request a review of the discharge decision. This request must be made by noon the day following receipt of the HINN to ensure continued Medicare coverage during the appeal process. You must make the request to a designated Quality Improvement Organization (QIO), an agency contracted by Medicare to review the appeal. The contact number for the QIO is listed on the HINN.
3. The QIO reviews the discharge decision and bases its decision on the medical records of the patient. A determination by the QIO takes place within two days of receiving a request for review by the patient or family.

If the QIO determines that hospital discharge is appropriate, Medicare will cover care until noon on the day following the decision.

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For a patient with a Medicare HMO, the appeals process begins with the hospital but involves different forms and also involves the HMO's own procedures. Again, the process is outlined in An Important Message From Medicare. For the appeal to be considered, care must be taken to follow the procedures and required time frame.

The best time to appeal a decision is when the patient is still in the hospital and the completion of necessary treatment can take place. However, a patient can appeal a decision up until 30 days after hospitalization. Medicare has been established to ensure that all necessary care is provided. The appeals process is in place to protect patients and the Medicare program.

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A Primer on Medicaid Coverage of Nursing Home Care

Anyone who considers nursing home care should become familiar with Medicaid, which is the major source of funding for such care.

Medicaid is funded by federal and state governments and administered at the state level; in Illinois, that means by the Department of Human Services. All states must comply with federal requirements, but each state has some discretion in creating eligibility and reimbursement levels. Unlike Medicare, which awards limited nursing home care regardless of income, Medicaid is based on financial need.

Finances are a key consideration in long-term housing decisions with and for the elderly. The cost of nursing home care ranges from $45,000-55,000 yearly. It doesn't take long for savings to be depleted. ElderCare Solutions recommends that families reserve, if possible, enough money for one or two years of nursing home care. A family may want to provide in-home care, but it's ill advised to spend all resources on such care only to find funds depleted if nursing home placement becomes necessary.

Nursing homes limit the number of "Medicaid beds." A nursing home can't deny placement because of payment source, but it may and often does have a long waiting list for people who need to enter the facility under Medicaid. Those beds are taken by residents whose funds have been depleted while in a nursing home.

In Illinois, an individual becomes eligible for Medicaid coverage when all but $2,000 in funds have been depleted. Medicaid allows for prepayment of funeral and burial. Once Medicaid is in place, the recipient is given $30 per month. All other income, including Social Security and pension, is applied to nursing home care cost, with Medicaid making up the difference.

When considering a nursing home, discuss whether the home accepts Medicaid and how a Medicaid bed can be assured when and if private funds are depleted. Most nursing homes will assist the family in the Medicaid application process, but the family must be involved and assume responsibility. If problems develop, the family will ultimately need to solve them.

Applying for Medicaid can be onerous. To avoid the pitfalls and headaches, ElderCare Solutions offers these recommendations:

• Begin the application well in advance. Don't wait until private funds are gone. Carefully account for all income and expenses once an application is submitted.
• The documentation required by the state is extensive. Collect all necessary documents before the application is submitted. An appointment with a caseworker is set up, usually within a few weeks of sending in the application. All documents should be brought to the appointment.
• Respond promptly to all notices sent by the Department of Human Services, even if to say the information is not available. Send all correspondence by certified mail.
• An application for Medicaid can be turned down for "insufficient" information, for materials not provided, or for information submitted after the deadlines. If an application is denied, the decision can be appealed. It is better to appeal a decision than to reapply, since Medicaid payment is based on the application date. If the appeal is successful, payment can be backdated to the original application.
• A number of legitimate and strictly regulated steps can be taken to preserve assets. If considered, asset preservation should be done well in advance of applying for Medicaid and preferably with the help of an elder law attorney.

While the Medicaid process at times is burdensome and appears arbitrary, it is important that a thorough review of all documents is undertaken to ensure the Medicaid system's integrity. However imperfectly we as a society address the long-term care needs of the elderly, Medicaid not only benefits the elderly but their families as well.

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Medicare Coverage of Home Health Care

The demand for skilled home health care has increased as the length of hospital stays has decreased. Medicare covers home care when the following conditions are met:

1. the care is ordered by a physician;
2. the individual is homebound or unable to leave without great effort;
3. a licensed professional is needed; and
4. the home care agency is licensed by Medicare.

To acquire nursing care under Medicare, the individual must require the assistance of a licensed professional. To be eligible for the care of a speech, occupational or physical therapist, the individual must have rehabilitation potential.

Medicare covers the cost of a home health aide for personal care, such as bathing or dressing, only if the individual requires the services of a licensed provider as well. Medicare does not cover personal care alone.

Medicare pays 80 percent of the approved cost for certain equipment needed at home, such as walkers, commodes and oxygen, when ordered by a physician.

When an elder is under the care of a physician for an acute illness, ask the doctor specifically about home care eligibility. If the elder is hospitalized, meet with the hospital social worker (sometimes known as a "discharge planner") early on to plan effectively for care upon discharge.

A quality home care agency performs an initial assessment and develops a home care plan. Ask to see the care plan and make sure these questions are answered to your satisfaction:

• What are the goals and the expected outcome of the home care to be provided?
• How many times per week will care or therapy be provided and for how many weeks?
• Who will provide the care or therapy?
• How will family members participate in the care?
• Is any teaching of the family incorporated to promote full recovery and prevent recurrence of the illness?

Medicare covers some, but surely not all, home health care needs. ElderCare Solutions encourages you to stay informed and ensure your elder receives all the care to which he or she is entitled.

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Medigap Pitfalls

Medigap insurance pays some of the deductibles for Medicare-covered services, and may pay for other services not covered by Medicare.

Medigap policies should be purchased during the federally mandated open enrollment period. "The worst mistake seniors are making is not shopping for Medigap during the 'window of opportunity' that Federal law provides," says Martin D. Weiss, president of Weiss Ratings, Inc., an independent organization which evaluates insurers and financial institutions.

The open enrollment period guarantees that for 6 months from the date a senior enrolls in Medicare Part B and is age 65 or older, he or she has the right regardless of any health problems to buy the Medigap policy of choice. A company cannot deny or condition the issuance or effectiveness, or discriminate in the pricing of a policy because of medical history, health status or claims experience. For a policy not purchased during open enrollment, the senior can be charged a higher premium or rejected because of medical problems.

For easier comparison shopping, most states limit the types of Medigap policies sold in their jurisdictions to 10 standard plans, designated by letters "A" though "J." Insurance companies cannot change the combination of benefits or the letter designations of any plan, and may offer one or more standard plans. All standard policies are guaranteed renewable.

Because the cost of policies vary widely, comparison shopping is important. Some policies are twice as costly as others for the same coverage. And, lower priced policies are often rated higher by independent organizations than pricier ones.

For more information, call ElderCare Solutions or request the 1997 Guide to Health Insurance for People with Medicare from the Illinois Insurance Department, 800/548-9034.

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Choose the Right Home Caregiver

In-home care is often required for an elder to stay at home. To secure quality home care, you must become an informed consumer of services.

Most long-term, in-home services are for such maintenance care as bathing and meals. Typically, families pay the costs out of pocket. Long-term care insurance may cover in-home care. To ensure optimum coverage, review the insurance eligibility requirements carefully.

A caregiver may be acquired through a home care agency, an employment agency or your own means. A home care agency screens applicants and monitors employees. It also pays the employment taxes and carries insurance in case of accident or injury. Many home care agencies are certified to receive Medicare funding and meet minimum government standards.

The hiring of an unaffiliated caregiver through an employment agency or through your own means is less costly than using a home care agency. With an unaffiliated caregiver, there is no ongoing agency involvement. Many such caregivers are excellent, although there is no quality control. Be sure to carefully check references and acquire worker's compensation insurance.

An unaffiliated caregiver is defined as either an employee or independent contractor. "Anyone who performs services for you is your employee if you can control what will be done and how it will be done," according to the U.S. Treasury Department. If the caregiver is your employee, you must deduct and pay the required employment taxes. An independent contractor defines the work to be done, how it will be done, and must make the tax payments.

To help establish a mutually satisfying relationship with a caregiver:

1. Write out a specific plan and job expectations, including personal care (e.g., bathing, toileting and exercise) and household duties (e.g., meals, shopping and housekeeping), or ask the caregiver for a plan;
2. Be honest about your elder's temperament, i.e., easygoing or demanding (remember, someone's behavior may be different with family members than with others); and
3. Identify one point person with whom the caregiver can discuss care and employment issues.

In-home care is a highly desirable option for many families, providing you find the right caregiver to match your family's needs and resources, and if you establish a mutually satisfying relationship. With the right caregiver, you can ensure that "there's no place like home" remains a positive refrain for the elder and the entire family.

Questions to ask a home care agency

• What specific services are provided?
• What is the charge for each service your elder may need?
• Is the agency certified to receive Medicare or Medicaid funding?
• Will services be paid by health insurance or Medicare?
• What qualifications are required by the home care agency?
• What specialized training or skills does the caregiver have?
• Who supervises the caregiver?
• Are services available 24 hours a day and on weekends and holidays?
• Will your elder have a consistent caregiver?
• If a caregiver does not arrive, will someone else be sent?
• What are the agency's safeguards to ensure caregivers are respectful?
• Is a written care plan provided? How often is it reviewed?
• Is it reviewed with the family and the elder's physician?
• How are complaints resolved??

Questions to ask an individual caregiver

• What experience have you had working with individuals who require care similar to my parent/elder relative??
• What training and skills do you bring to this position??
• What do you enjoy most about working with the elderly??
• How would you handle a situation when an elder refuses medication or care??
• what possible emergencies can you foresee and how would you handle them??
• Whom will you call for help if you have difficulty handling a situation alone??
• Can you provide several references?

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Keep Current with Medications

Prescription medications improve an elderly person's quality of life. But with medications, as with so many things in life, very often less is more.

Individuals over 65 years old receive a full one-third of all prescription medications and purchase about 70% of all over-the-counter medications. Because of physiological changes, the elderly are at higher risk for adverse drug reactions. Taking numerous medications for one or more chronic conditions increases the risk even further. While adverse drug reactions are estimated to occur in 2-10% of younger adults, that number soars to 20-25% in the elderly.

Among the most common side effects of medications are: cognitive changes, such as confusion, memory loss and sedation; changes in blood pressure; and incontinence or other changes in bladder and bowel functions. Taking more than three different medications increases the risk of a fall. Some of the changes that may be dismissed as part of aging are in fact the result of the adverse effects of medication.

Inherent risks exist in every medication. To help your elders receive the greatest benefit from medications with the fewest side effects, ElderCare Solutions suggests the following:

1. Inform all physicians your elder sees of all medications that have been prescribed. An increasing problem in medication management has resulted from multiple medications being prescribed by different specialists for concurrent problems.
2. Find out what each drug is intended to do and if there are non-medicinal ways to treat a problem, such as a change in diet or exercise.
3. Ask about side effects. Are there foods, medications or activities that should be avoided when taking a medication, and conversely, can foods or activities enhance a medication's effectiveness? How long will the elder need to take a medication? How will you know if it's working?
4. Use one pharmacy and establish a relationship with the pharmacist, who is often an untapped wealth of information. Make sure pharmacy records are up to date regarding allergies and drug reactions. Ask your pharmacist about prescription drug interactions with over-the-counter medications.
5. Review medications with physicians and pharmacists each time a new medication is prescribed to ensure that the new medication does not adversely interact with others. Periodically review all medications with the physician. Medications are frequently added, but not often eliminated.
6. Don't stop taking a medication without consulting your physician. Some medications need to be reduced gradually to prevent detrimental side effects.
7. Many older adults ask very few questions of their doctor for fear the doctor will think they're "questioning" his or her judgment. Let your elder know you want to be involved to ensure their well-being and your peace of mind.

Responses to medications vary from individual to individual. Family and elder involvement in medication management creates a healthy relationship with your health care provider and in turn can be an important safeguard against health-threatening drug reactions.

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A Primer on Reverse Mortgages

A reverse mortgage is a relatively new way for a homeowner, age 62 or older, to use the equity in his or her home without selling or acquiring a loan with monthly payments. The primary reason older adults consider a reverse mortgage is that it provides cash, thus enabling them to stay in their own home.

As in every financial transaction, take a "buyer beware" stance and be sure you understand the terms and costs of the mortgage. Also, before getting a reverse mortgage, look at alternatives to staying in one's own home, compare the costs of staying or moving, and review any available public programs that supplement costs of living.

A reverse mortgage can be paid out as follows:

• in a single lump sum;
• in regular monthly cash payments; or
• as a credit line that can be used at any time.

The amount of the loan and how it is paid out may effect the eligibility for public benefit programs that are based on assets.

Unlike a regular mortgage in which the debt decreases over time, in most reverse mortgages debt increases while home equity decreases. With a reverse mortgage, the individual retains home ownership. Property taxes, insurance and repairs remain the owner's responsibility. The amount of the reverse mortgage cannot exceed the home's value. The lender can't look to sources other than the home for repayment. The loan doesn't have to be repaid until the owner dies, sells the home or permanently moves out.

The several types of reverse mortgages include a Home Equity Conversion Mortgage (HECM), offered by the private sector, and the Fannie Mae "Home Keeper" reverse mortgage, offered by a publicly-held lending company. Each has distinct features. The loan amount available depends on age, current interest rates and the home's value. While federal regulations limit the fees associated with a reverse mortgage, fees do differ between lenders. It pays to shop around.

Anyone seeking a HECM or Fannie Mae Home Keeper loan must first participate in a counseling or consumer information session. The borrower learns the benefits and limits of various types of reverse mortgages and other viable options to meet short- and long-term finance needs.

For more information, contact:

• AARP - www.aarp.org/revmort or call 800-424-3410 for a free booklet.
• Fannie Mae - www.fanniemae.com or call 800-7-FANNIE.

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