CDISNM Blog
Many elderly need specialized long-term care – social and medical services that traditionally take place in nursing homes. Seniors who are over the age of 55 and in need of care may be eligible for Programs of All-inclusive Care for the Elderly, or PACE. A Medicare program designed to provide personalized, coordinated care for the disabled in a community setting, the goal of PACE is to help seniors preserve their independence and delay nursing home care as long as possible. Here is some information on the PACE program and how it works to help older adults in need of services.
Eligibility and Cost
Enrollment in the PACE program is involuntary, but to be eligible to receive benefits, seniors must meet a few conditions. Applicants must be at least 55 years old and certified by the state as requiring a nursing home level of care. Recipients must reside in the service area of the PACE organization and be capable of living safely in the PACE community. Seniors who are eligible for Medicare, Medicaid, or both can enroll in PACE. While PACE uses Medicare and Medicaid funds to pay for care and services, the cost of the program depends on each applicant’s financial situation. Medicaid recipients may pay nothing at all or a small fee for services. Medicare-only recipients who join PACE pay a monthly premium for long-term care and prescription drugs. In either case, there are no deductibles or coinsurance.
Benefits
PACE benefits include all Medicare and Medicaid-covered services in addition to some services not covered by Medicare. This includes doctor and nursing services through a primary care physician, care while in the hospital (including laboratory and x-ray services), emergency services, physical and occupational therapy, nursing home and home care, prescription drugs, dental, meals, and nutritional counseling, social services, and transportation. Seniors who enroll in PACE receive all of their Medicare benefits through the program.
Each applicant is assessed daily on an individual basis by a team of skilled healthcare professionals. The team consists of the following:
Primary care physician
Activity Coordinator
Nurse
Dietitian
Social Worker
Center supervisor
Physical therapist
Home care liaison
Occupational therapist
Driver
Is PACE the Right Choice for You?
For older adults suffering from a disability or chronic condition, having medical and supportive services available in a community setting offers peace of mind, promoting independence and delaying nursing home care. The mission of PACE is to help well-deserving seniors and their families accomplish this goal by offering comprehensive medical and social services provided by a team of interdisciplinary health professionals. Individual states elect to provide PACE benefits to Medicaid recipients.
References:
https://www.medicare.gov/your-medicare-costs/help-paying-costs/pace/pace.html
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CDISNM Blog
Seniors suffering from debilitating chronic health conditions may be eligible to join a Medicare-approved Special Needs Plan (SNP). An SNP provides additional benefits above and beyond Original Medicare, offering seniors with special care requirements the treatment and services they need. What is a Special Needs Plan and who qualifies? The following information can help you understand eligibility requirements and plan details to determine if a Medicare Special Needs Plan is the right choice for you.
Special Needs Plan
Treatment of certain chronic health conditions such as cancer or dementia may require additional services above and beyond that which Medicare provides. For many seniors, the extra cost associated with treatment is a burden and Special Needs Plans address these concerns. Most benefits provided by an SNP are paid in full for recipients who are enrolled in both Medicare and Medicaid. However, for seniors who do not qualify for Medicaid, participating in an SNP costs about the same as enrollment in a typical Medicare Advantage plan.
Eligibility
To be eligible to join a Medicare Special Needs Plan, you must be enrolled in Medicare Part A and Part B, reside in the plan’s service area, and meet specific medical requirements. Seniors with a disabling chronic condition or who live in a nursing home, require in-home care or currently receive both Medicare and Medicaid benefits may qualify. SNPs may not be available in all states as insurance companies providing benefits decide which counties will offer coverage.
What Qualifies as a Chronic Condition?
Many seniors face chronic health conditions with age. However, to qualify for a Special Needs Plan, seniors must have one or more of the following chronic conditions:
Alcohol or drug dependence
Hematologic disorder
Autoimmune disorder
HIV/Aids
Cancer
Chronic lung disorder
Cardiovascular disorder
Disabling mental health conditions
Chronic heart failure
Neurologic disorder
Dementia
Stroke
Diabetes
End-stage liver disease
Is a Medicare Special Needs Plan Right For You?
Navigating Medicare and available benefits can be challenging, and it’s always a good strategy to learn as much as you can about all programs that may be able to help. If you are suffering from a chronic condition, an SNP may be the right choice. With an increased network of providers who specialize in treating your condition and additional benefits, getting the care you need and deserve may be easier than you realize.
References:
https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/special-needs-plans.html
https://www.medicare.gov/Pubs/pdf/11302.pdf
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CDISNM Blog
An emergency, even regular medical care can cost thousands of dollars, leaving many people without the finances to get the care they deserve. How does Medicaid help people pay medical bills? A state and federally-funded health insurance program, Medicaid is designed to help low-income adults, children, pregnant women, and seniors get the medical care they need. To be eligible for benefits, recipients must meet the required income level and family size. If you are interested in learning more about Medicaid assistance, here is some information that can help.
Eligibility
Currently, Medicaid provides health coverage to over 70 million seniors, children, pregnant women, and those with disabilities. Income-based eligibility is determined using the federal poverty level, which is updated annually. Since 2014, when the Affordable Care Act passed, Medicaid eligibility has expanded. However, in addition to placing income requirements on recipients, states may charge enrollees a premium, along with copayments, deductibles, and coinsurance for receiving benefits. Children and pregnant women are excluded from many of these fees, but all applicants must meet state and federal requirements concerning residency, immigration status, and documentation of U.S. citizenship.
Coverage
While Medicaid benefits vary from state to state, each state must meet certain mandatory federal minimum requirements. In general, the program pays for basic inpatient and outpatient hospital services, nursing and home health care, laboratory and x-ray services, pediatric care, and necessary medical equipment. Many states have expanded the mandatory federal minimums to include benefits for physical, occupational, and speech therapy, optometry, podiatry, dental and vision care, chiropractic services, hospice care, and more. Often, benefits are provided through Medicaid that are not covered by Original Medicare, such as personal care and homemaker services. In some cases, Medicaid covers out-of-pocket expenses associated with Medicare, like premiums, deductibles, and coinsurance.
Dual Enrollment
Dual eligibility in both Medicaid and Medicare is common, and millions of seniors receive benefits from both programs. As a Medicare recipient with low income, Medicaid may be able to help pay for out-of-pocket expenses associated with Original Medicare. In addition, Medicaid often covers treatment and services not typically covered by Medicare, such as prescription drugs, eyeglasses, and hearing aids. If you qualify for Medicaid benefits, you may be eligible to receive retroactive coverage that can help pay for medical debts you incurred up to three months before applying.
References:
https://www.medicaid.gov/medicaid-chip-program-information/by-topics/eligibility/seniors-and-medicare-and-medicaid-enrollees.html
https://www.medicaid.gov/medicaid-chip-program-information/by-topics/cost-sharing/cost-sharing.html
https://www.medicaid.gov/medicaid-chip-program-information/by-topics/eligibility/eligibility.html
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