It is no secret that most Americans would prefer to remain at home to the
end of their life. This desire has
brought about many types of care aimed at keeping individuals at home or
simulating a home-type environment when that is not
possible.
Medicare
and Medicare Supplemental Policies
At
one time it was often assumed that Medicare and Medicare supplemental policies
would provide care at home. While
Medicare does provide some home care, not all people will qualify for it. The
Medicare handbook titled Medicare & You 2004 states Part A of Medicare will
cover part-time or intermittent skilled nursing
care and home health aide services, physical therapy, occupational therapy,
speech language therapy, medical social services, durable medical equipment
(such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and
other services.
If the insured qualifies under Medicare, the insured will
pay nothing for home health care services, although they must pay 20 percent of
the Medicare-approved amount for durable medical
equipment.
It is
very important to note the qualifying statements regarding Medicares coverage
for home care. Medicare only pays
for part-time (not full-time) care and the care must be skilled. Medicare will not cover personal care at
home. The person may receive an
unlimited amount of visits by home health care personnel as long as the patient
meets all of Medicares requirements.
As we said, the patient will pay nothing for these visits since Medicare
will cover all eligible costs.
The key word here is eligible.
To be considered eligible:
1.
A doctor must certify
the need for home health care.
2.
The treatment must
require only part-time not full time skilled nursing care, physical, speech,
or occupational therapy.
3.
The patient must be
homebound, unable to do an outside normal routine of shopping or other daily
routine chores.
4.
A doctor must set up
the home health care visits under a plan of care, which is provided by a
Medicare contracted home health care agency.
California
Home Care Requirements
In
California every long-term care policy or certificate that provides benefits for
home care or community-based services must provide at least the
following:
Under Senate Bill
1943 every long-term care policy that provides home care benefits must allow a
threshold of eligibility that is at least as permissive as those for nursing
home care. This would relate to
needing assistance in performing 2 or more ADLs or having a cognitive
impairment.
Benefits may not be
contingent upon standards using such words as usual and
customary.
Policies must be
either guaranteed renewable or noncancelable.
Policies may not describe or put restrictions on long-term care services
that are at odds with state or federal law. It is very important that agents make
consumers aware of any requirements that limit benefit eligibility. Policies cannot duplicate benefits paid
by Medicare.
Home Care Policies Must Cover Specific
Benefits
California does have services that are mandated under a home care
policy. If a policy provides
benefits for home care or community-based services, it must provide at least the
following:
1.
Home health
care
2.
Adult day
care
3.
Personal
care
4.
Homemaker
services
5.
Hospice
services
6.
Respite
care
Long-term care facilities do not provide the same care given in
hospitals, so acute care services will not be provided. 10232.9 (a)
Each
of the mandated services has a distinct definition. They are:
Home Health Care: skilled nursing or other professional services in
the residence, including part-time and intermittent skilled nursing services,
home health aid services, physical therapy, occupational therapy, or speech
therapy and audiology services, and medical social services by a social
worker. It should be noted that
home care is different from home health care. Anytime the word health is inserted
the type of care offered is more specific.
Adult Day Care: medical or non-medical care (medical care will be
stated as adult day health care).
It is provided on a less than 24-hour basis and usually occurs outside of
the patients place of residence.
Personal Care: assistance with the activities of daily living,
including the activities that might be performed by either a skilled or
unskilled person under a plan of care developed by a doctor or a
multi-disciplinary team under medical direction. Another term often used is instrumental activities of daily
living. This would include using the
telephone, managing medications, moving about outside, shopping for essentials,
preparing meals, and light housekeeping.
Homemaker Services: assistance with the activities that are necessary
for the insured to remain in his or her own home. A skilled or unskilled person might
provide the activities under a plan of care developed by a doctor or a
multidisciplinary team under medical direction.
Hospice Services: outpatient services not paid by Medicare that are
designed to provide palliative care, alleviate physical, emotional, social, and
spiritual discomforts associated with the last phases of life due to a terminal
disease. Hospice provides care by a
skilled or unskilled person under the direction of a doctor or a
multidisciplinary team directed by a doctor.
Respite Care: short-term care provided in another setting, or in
a community-based program that is designed to relieve the primary caregiver in
the home. This is a separate benefit with its own conditions for eligibility and
maximum benefit levels. 10232.9
(b)
Policies
May Not Place Some Limitations on Coverage
Although most policies have some type of benefit limitations, California
prohibits some limitations.
California policies may not limit benefits by:
1.
Requiring a need for
care in a nursing home if home care services are not
provided.
2.
Requiring that
skilled nursing or therapeutic services be used before or with unskilled
services.
3.
Requiring the
existence of an acute condition.
4.
Requiring services
from a Medicare-certified agency or provider only.
5.
Requiring services be
provided by a licensed or skilled person when others could provide the services
equally as well, except where prior licensure or certification is required by
state law.
6.
Defining an eligible
provider in a way that is more restrictive than that used to license the
provider by the state where the service is provided.
7.
Requiring medically
necessary or similar standards as a criteria for
benefits.
10232.9 (c)
Avoiding
Institutionalization
Not
everyone will need to enter a nursing home. Some will have enough stability of
health to enable them to remain at home with outside help. Care at home is sometimes still
considered long-term care due to the nature of help required. AARP has reported that 40% of nursing
home admissions are due to a fall that results in an injury.[1] Some will only be in the nursing home
long enough for the injury to heal, but many others will remain there because
their overall health is poor or because they are frail.
One
of the problems concerning long-term care is identifying who is most at
risk. Of course, anyone can end up
in a nursing home due to simple aging and the frailty that comes with it. When rehabilitative resources are not
able to restore personal independence, the nursing facility will then become
home for the remaining duration of life.
If, on the other hand, there are resources to maintain partial
independence while living at home an individual may be able to avoid the nursing
home as their final place of residence.
The
deciding factor between remaining at home and becoming a patient at a nursing
facility of some type often depends upon the physical factors involved and the
amount of help available from family and friends. Mildreds progression in our example in
chapter one was a gradual decline in health that eventually led to the nursing
home. Because Mildred had children
who were willing (and most importantly able) to help her, she was able to remain
at home longer than would otherwise have been possible. According to Californias Long-Term Care
Factsheet, printed by the California Partnership for Long-Term Care,
approximately 200,000 older Californians have three or more limitations, but are
still able to remain at home or outside of a nursing home. Therefore, merely having physical
limitations will not necessarily send a person to the nursing home. So, the question remains: Who will go
to the nursing home? If only
each of us had a crystal ball!
We do
know from a number of different studies that access to caregiver and community
services can reduce the utilization of nursing homes. What does this mean? It means that those who can take
advantage of programs designed to allow them to remain at home are more likely
to succeed in this goal.
California, along with several other states, has done an excellent job in
providing alternate services, although the California Department of Insurance
has reported that actual nursing home admissions have risen by 40% since
1983. An important element for
remaining at home continues to be the support of family members who help without
receiving pay. Friends may also
lend a hand, but typically an elderly persons friends are experiencing similar
problems because they are also aging.
Although there are factors and programs aimed at helping people remain at
home until their death, we cannot ignore the facts: for those currently between
the ages of 65 and 69 there is nearly a one-in-two chance of entering the
nursing home.[2] The only thing each of us can do is look
at our familys medical history for guidance and at our immediate family for
help. Longevity is considered a
factor that will lead to needing a nursing home, since simple old age and the
resulting frailness that goes along with it often is the reason a person
eventually goes to the nursing home.
Children
As Caregivers
When
it comes to our parents and aging, the numbers tell the
story:
Percentage of
caregivers who are female: 60%
Percentage of
caregivers who are married or living with a partner: 66%
The average age of
the caregiver: 46 years old
The average age of
the care recipients: 77 years old
Percentage of
caregivers who have children under the age of 18 still living at home:
41%
The percentage of
caregivers who are employed full time: 52%
The caregivers
out-of-pocket monthly expenses associated with the care:
$221
The median family
income of the caregivers household: $35,000 [3]
Gary
Barg, editor in chief of Todays Caregiver magazine based in Florida
states that about a fourth of U.S. households care for an aging relative in some
way. [4] Few Americans expect to do this (it will
always happen to someone else they think).
Unfortunately, few families prepare for it either. The U.S. Census Bureau says that by
2050, the percentage of Americans 65 and over will grow to 21 percent of the
population from the current 12 percent.
Approximately 19 million elderly are expected to need some type of long
term professional care. If the
family cannot afford alternatives, such as assisted living, it is likely that
the children will provide the care themselves, whether they have prepared
themselves adequately or not.
Deputy director of the National Center on Caregiving at Family Caregiver
Alliance in San Francisco, Lynn Friss Feinberg, says: It affects
everyone. She reports that it is a
myth that the majority of our elderly go to nursing homes. Its not what the baby boomers want,
she says.
Gail
Gibson Hunt, the executive director of the National Alliance for Caregiving,
reports that many caregivers feel isolated and alone. While family caregivers are facing
everything from mild supervision of their family members to full time care,
legislation addressing the situation is still mainly in its infancy. In 2000, Congress established the
National Family Caregiver Support Program in which the government provides
funding to each state for caregiver services, such as respite care, education
and training. But the 2003 budget
for the entire country was only $155.2 million, which Hunt calls a drop in the
bucket. Funding for 2004 was $159
million.
A few
states have passed legislation. In
2002, California led the nation in passage of a paid-family-leave law. Hawaii passed a law in 2003 that allows
employees to use sick leave for family purposes. Congress has considered various
initiatives but nothing solid has yet come.
While
many families cope well with caring for an elderly parent, others do not. Primarily it will depend upon the
support they receive from their family and their community. While caring for elderly parents is
similar to raising children, the process goes in reverse. Children grow and learn and become
increasingly independent whereas the elderly become more and more dependent upon
their caregivers.
Can
Families Make It Through?
There
are families that do completely care for their elderly members, but most
families say success depends upon community services to help them and provide
periods of rest. Most communities
have some form of help, though not necessarily for free. The families that will handle it best
are those lucky enough to have personal financial resources to pay for
help. There are some places to turn
for information, whether financial resources exist or not. These resources
include:
Eldercare Locator:
800.677.1116 or www.eldercare.gov
Family Caregiver
Alliance/National Center on Caregiving: 800.445.8106 or
caregiver.org
National Alliance for
Caregiving: caregiving.org
Alzheimers
Association: 800.272.3900 or www.alz.org
Faith In Action:
877.324.8411or fiavolunteers.org
National Academy of
Elder Law Attorneys: 520.881.4005 or http://www.naela.org/
National Association
of Professional Geriatric Care Managers: 520.881.8008 or
caremanager.org
Caregiver.com, Todays Caregiver
magazine
Paid
Home Care
Next
to the spouse and children, paid home care is the most commonly used method to
remain at home. Many of the paid
home caregivers do not show up in statistics because the family pays for it out
of their own pocket. The caregiver
is not licensed, in these cases, with any medical agency.[5] These unlicensed and medically untrained
caregivers provide an important service.
They do the daily routines necessary to keep the individual at home
(called activities of daily living).
The type of care non-medical people provide is called personal care. 10232.9 (b)(3)
Personal care is assistance with the activities of daily living provided
by skilled or unskilled persons under a plan of care developed by a physician or
a multidisciplinary team under medical direction. To the general consumer, personal care
means a chance to stay at home, hopefully for the duration of their life. California requires long-term care
insurance policies to provide benefits for care rendered by unlicensed providers
if the state has no licensing requirements for that particular service and the
insurance policy would have covered the service if it were provided by a
licensed agency. The care does not
necessarily have to be provided in California. Once the policy is issued in California,
those services must be delivered as prescribed by the policy regardless of where
the care is received. Services
cannot be limited to those provided by licensed practitioners, when those types
of service do not require a state or federal license. This aspect of Californias policies
actually saves the insurance company money since it allows families to hire help
at a lower rate. It also helps the
family because it allows them to hire help within the benefit level of the
policy.
Is it home care or home health
care?
There
are two types of care provided at home: home care and home health care. As the word implies, home health care
deals specifically with health care issues not just the activities of daily
living. When health issues are
involved the type of person hired often needs some type of medical
training. It usually involves
part-time or intermittent skilled nursing services by licensed nursing personnel
provided by a home health agency at the persons residence. When medical care is required the cost
of such care is bound to be higher than non-medical care. It would be unusual for family members
to have the skills necessary to provide medical care so it is likely that such
help must be hired.
10232.9 (b)(1)
Community
Services
When
care at home is possible from a medical standpoint, there are community services
that can help.
Adult Day
Care
Adult
day care is considered to be a form of long-term care. It may be either medical or
non-medical. Adult day care may be
provided by a number of agencies, including churches, hospitals, and for-profit
organizations. Like childcare, the
participating individuals come to a specified location where there is daytime
supervision, structured activities, meals, counseling, and medical treatments
available. Some provide
transportation as well. Adult day
care is not 24-hour care; rather it is for a specified time period usually
during the day, although there may be some centers that will also care for a
person during the night. These
centers are designed to aid individuals in their goal of remaining at home for
as long as medically possible.
10232.9 (b)(2)
Adult
day care is specifically designed to help an elderly or ill person remain at
home. It should be noted that not
just the elderly use adult day care services. Younger people with injuries or grave
illnesses also utilize this type of care.
In
California, adult day care has three distinct designs:
1.
adult day health
care,
2.
adult day social
care, and
3.
Alzheimers day
care.
California policies that offer benefits for home care must also cover
benefits for adult day care.
Chore
Services
Chore
services may come under a variety of names and handle an assortment of services,
such as general housecleaning, minor household repairs, snow removal, and
general household chores. Payment
for these services is not likely to be covered by a long-term care
policy.
Homemaker
Services
Homemaker services have similarities with chore services, but they tend
to be more personal in nature.
These services would include driving the individual to and from
appointments or to shopping areas, changing bed linens, cooking meals and
cleaning up afterwards, helping with personal needs, such as washing their hair,
and just generally giving assistance where needed. Homemaker services allow an individual
to remain in their home. The person
providing the services generally do not have specific medical skills but the
care is provided under a plan of care developed by a physician or other medical
person. 10232.9
(b)(4)
There
are agencies that provide these services, but many people simply hire someone
they know from their neighborhood.
The hired homemaker is often a relative, friend, or
neighbor.
What is an Independent Living
Service?
A
wide variety of services can come under the heading of independent living
services. The options available
will depend upon the service providing them. Some provide home-like settings in an
apartment (although there may not be full kitchen privileges), adult day care
services, chore services, emergency response systems, homemaker services, Meals
on Wheels, personal contact services, and transportation services. Providers of these various services may
be for-profit organizations, government based, or non-profit
organizations.
Many
services are provided by volunteer organizations. Volunteers who donate both their time
and cars driving elderly people to and from medical appointments and shopping
areas may provide transportation.
Volunteers may also monitor medications or make daily or weekly telephone
calls to stay in touch with the elderly.
What
happens when living at home
just
isnt possible any longer?
When
care at home is no longer possible, the first consideration should be a
home-like setting. There are
facilities that strive to provide this.
Of course, in some cases, a nursing home is the only safe and realistic
option, but when other care settings are available and can provide the level of
care required, it is always worth considering.
What is a Residential Care Facility
for the Elderly?
When
care at home is no longer possible, the next best thing is a simulation of care
at home. That is what Residential
Care facilities attempt to offer.
Senate Bill 870 requires care in a residential care facility to be
covered. Residential care
facilities are licensed as a residential care facility for the elderly or
RCFE, as defined in the Health and Safety Code. Outside of California, eligible
providers are facilities that meet applicable licensure standards and are
engaged primarily in providing ongoing care and related services sufficient to
support needs resulting from impairment in activities of daily living or
impairment in cognitive ability.
Care must be provided on a 24-hour basis with trained personnel ready to
respond to the residents needs at all times. The facility must serve three meals each
day and accommodate special dietary needs, have agreements to ensure that
residents receive the medical care services of a doctor or nurse in case of
emergency, and have appropriate methods and procedures necessary to provide
assistance to the residents.
10232.92 (a)
Although RCFEs provide a wide range of
services, they are not nursing homes and they do not provide skilled care. They do an excellent job in the capacity
for which they are intended. RCFEs
provide a place to live and specific kinds of care that assist a person to live
as close as possible to the way they would have at home.
Where
home care must be at least 50 percent of the institutional benefit, RCFE
benefits must be no less than 70 percent.
Of course, the policy may pay higher amounts, just not less. Therefore, if the institutional benefit
per day were $100 (the lowest allowed), the RCFE benefit would be $70 per day.
All expenses incurred by the insured while confined in a residential care
facility for long-term care services that are necessary diagnostic,
preventative, therapeutic, curing, treating, mitigating and rehabilitative,
maintenance or personal care services that are needed to assist the insured with
the disabling conditions that caused the chronic illness must be covered by the
policy up to but not to exceed the maximum daily residential care facility
benefit stated in the policy or certificate. There can be no restriction as to who
may provide the service or the requirement that services be provided by the
residential care facility, as long as the expenses are incurred while the
insured is confined there as a resident.
However, the services may not conflict with federal law or regulation for
purposes of qualifying for favorable tax consideration provided under Public Law
104-191. 10232.92
(b)(c).
In
policies that are not intended to be federally qualified, the threshold
establishing eligibility for care in a residential care facility must be no more
restrictive than that for home care benefits, and the definitions of impairment
in activities of daily living and impairment of cognitive ability must be the
same as for home care benefits.
10232.92 (d)
In
policies that are intended to be federally qualified, the threshold
establishing eligibility for care in a residential care facility must be no more
restrictive than that for home care benefits and the definitions of impairments
in activities of daily living and impairments in cognitive ability must be the
same as for those for federally qualified home care benefits.
10232.8
All
long-term care policies and certificates must define the maximum lifetime
benefit as a single dollar amount that may be used interchangeably for any home-
and community-based services, assisted living benefits, or institutional care
covered by the contract. There
cannot be a limit on any specific covered benefit except for the daily, weekly,
or monthly limit set down for home- and community-based care, for assisted
living care, or institutional care, as provided in the contract. 10232.93.
RCFE
Definitions
Some
policies specify which type of facility is covered under the policy: skilled,
intermediate, or custodial. It is always best to have all types of care covered
equally. If a policy limits which
facilities are covered, it will be either skilled or skilled and intermediate
facilities that are specified. A
custodial facility would not provide skilled or intermediate care. In California, custodial care is
provided in a variety of settings.
Nursing homes in California provide both skilled and custodial care. There is no license category in
California for just custodial care.
There might be in other states, however. In addition, intermediate care is being
phased out. California does have a
license category called Residential Care Facility
for the Elderly (RCFE), which may be comparable to custodial
facilities or assisted living facilities in other states.
It is
very important to understand the difference between a skilled nursing home and
an RCFE. A nursing home provides
primarily skilled, intermediate, and custodial care. A Residential Care Facility for the
Elderly provides custodial care, as well as personal care associated with the
activities of daily living. RCFE is
a license category in California; that is an important
distinction.
Insurance companies that market LTC policies issued in California are
required to use definitions that describe nursing homes in California. Companies may not use limitations that
go against state requirements.
Californias Health and Safety Code, Chapter 2 commencing with Section
1250 states that a long-term health care facility means any facility that is
licensed according to these regulations.
Therefore, any of the following could be classified as a long-term health
care facility in California:
Skilled nursing
facility
Intermediate care
facility
Intermediate care
facility for the developmentally disabled
Congregate living
health facility
Nursing
facility
A
hospital would not be included unless it had provisions within it that met the
requirements for long-term care.
What is a Life Care
facility?
A
life care facility combines housing and nursing home care. The name, Life Care, is an attempt to
describe that concept. While the
type of housing offered can vary, usually there is both residential and nursing
care available on the same parcel of land.
There may be apartment complexes, duplexes, or cottages available prior
to needing nursing home care. Once
health deteriorates, the individual merely moves from one building to another on
the same grounds. Since the options
available can vary widely, no one should jump hastily into any contract with a
life care corporation. First, an
attorney should be consulted as well as a health care professional for their
opinion.
What is a Continuing Care
Community?
Life
Care Facilities and Continuing Care Communities tend to be very similar. The idea is primarily the same: to offer
care under a variety of health and living conditions. The goal is always to delay admission to
the nursing home.
What is Congregate
Housing?
Congregate housing may also be known as Congregate Care. This is characterized by a building
meant to house anywhere from a few people in a home-like setting to several
hundred in an apartment building.
Each resident has their own bedroom, although some communities may offer
reduced rates to those willing to share a room. Each resident has their own bathroom or
they share one with a second individual.
There are no living rooms, kitchens or other rooms typical of living in a
house. The dining room is a
communal setting where everyone eats together. Congregate housing includes three meals
a day. There may be a community
library, sewing room, exercise room, or other
conveniences.
Statistics show that those who choose congregate housing over retirement
apartments are usually 75 years old or older and tend to be less
independent. They are seeking a
living situation that offers them some of the qualities seen in a nursing home,
but with more independence than would be offered there. These individuals do not yet need
24-hour care, but they do need help on a daily basis.
Our
government funds much of the congregate care available through its Congregate
Housing Services Program.
Low-income individuals may receive subsidized rent payments, although the
waiting list is often long.
End
of Chapter Four