Information for Caregivers
If you find yourself in a situation where you are helping a loved one manage their health condition, treatment, and paying for medical expenses, you have more than likely become their caregiver.
As a caregiver, you will be asked to make important recommendations and decisions on behalf of your loved one. Because of your role, it’s important to understand how the Medicare program works and the options within each plan. It is crucial you make the best decision or recommendation for your loved one so they can make the most of his or her Medicare coverage.
Understanding your loved one’s Medicare coverage
Once you have been identified as a caretaker for someone due to their medical condition, you will first want to talk to someone else who knows the person being taken care of. You will want to understand what their needs are and who has permission to act on his or her behalf.
You will then want to find out who their current health insurance carrier is. If they have Medicare, you’ll want to find out if the coverage is with Original Medicare (Part A and Part B), Medicare Advantage, or a Medicare Supplemental Plan. It’s also important to find out if the person has prescription drug coverage. This information can be found on the Medicare card. If they have a Medicare Advantage or a Medicare prescription drug plan, there will be a separate plan member card.
If you are unable to access the Medicare card, you will want to call Medicare with the beneficiary, or have them complete an authorization form to release information to you. To obtain the authorization form, call 1-800-MEDICARE.
If the beneficiary is not enrolled in Medicare, you will first obtain their enrollment eligibility date. While working with the beneficiary to manage their healthcare, make sure to have the following information available:
- Social Security number
- Medicare number and type of coverage
- Insurance plans and policy numbers
- Contact information for healthcare professionals
- Current list of prescription(s) and other drugs
- Any information on current health conditions or treatments
- Health history
- List of allergies or food restrictions
- Emergency contacts
- Location of all financial and legal information (living will and medical power of attorney)
The State Health Insurance Assistance Program gives free health counseling and guidance to caregivers who have authorization to help someone with their Medicare. It’s a great resource to contact if you have any questions. In some states, SHIP is known as SHIBA or SHINE.
Paying for Medicare and health-care costs
It’s important for caregivers to find out if there is any other health coverage to use besides Medicare. For example, the beneficiary could have a health plan with a former employer, Medicaid, or another insurance that can help pay for health related expenses.
Depending on the income level and available resources, there may be other programs that can help in paying for health related expenses. Programs like the Medicare Savings Program (MSPs) help in paying for copayments, premiums, and deductibles for low-income individuals.
Other options are the Medicare Extra help program, which assists with prescription drugs, and the state Medicaid programs, which help with medical and care expenses.
Illness and hospitalization
As a caregiver, it is best to speak openly with the individual receiving care about any illness or treatment. They should be aware of what the doctor recommends during each office visit. If the beneficiary is involved and aware of the facts, this will relieve concerns they may have and give them a clear understanding of their health situation. Being emotionally supportive is an important part of managing someone’s care.
It is important to understand the type of coverage Medicare Part A offers in cases where hospitalization is needed. It’s best to obtain a second or even third opinion in cases where the beneficiary’s doctor recommends surgery or major testing. By obtaining multiple opinions, more information can be used when deciding on the best course of action for one’s health.
Beneficiaries with Original Medicare do not need referrals to see additional doctors who are not their primary care doctor. Medicare Advantage plan (HMOs) individuals may need referrals from their primary care doctor to obtain a second or third opinion from another doctor.
If using Original Medicare, you should find out if the doctor or medical supplier accepts assignment before moving forward with the care. This is an agreement between doctors, healthcare providers, and suppliers to accept Medicare approved amounts as payment in full. If they accept assignment, the beneficiary will be responsible for the cost sharing with, for example, the deductible or co-payment. If hospitalization is needed, Medicare covers inpatient hospital care when the following is true:
- The doctor states that inpatient hospital care is medically necessary for treatment
- The care needed can only be given only in a hospital
- There is an agreement between the hospital and Medicare
- The hospitals Utilization Review Committee approves the stay
If a beneficiary is hospitalized, Medicare aids in paying for certain services:
- General nursing care
- Semi-private room
- Hospital services i.e. meals and supplies
If a beneficiary is hospitalized, Medicare will NOT pay for the following services:
- Private-duty nursing
- Private room (unless medically necessary)
- Hospital services i.e. television and telephone
- Personal care items like razors and toothbrushes
For more information about Medicare Part A, visit www.medicare.gov.
Medicare prescription drug coverage
To receive Medicare prescription drug coverage, a beneficiary should join a prescription drug plan managed by an insurance company who is approved with Medicare. All prescription drug plans vary in costs and coverage. There are currently two options for getting this type of coverage:
- Medicare Prescription Drug plan (PDP)
The beneficiary must be enrolled in Medicare Part A and/or Part B and also live in the service area of the Medicare prescription drug plan. These plans add coverage to Original Medicare, some Medicare Cost plans, some Medicare fee for service (PFFS) plans, and Medicare Medical Saving Account (MSA) plans.
- Medicare Advantage Prescription Drug (MAPD) plan
Similar to an HMP or PPO, to join this plan the beneficiary must have Original Medicare, Part A and B. Medicare Advantage (MA) plans like Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO) or other plans may include prescription drug coverage. In these cases, the beneficiaries would get all their Medicare coverage through these Medicare Advantage Prescription Drug (MAPD) plans.
Other types of prescription coverage
In some cases, beneficiaries have both prescription coverage and Medicare. For example, this prescription coverage could be through an employer sponsored plan or veteran benefits. When this happens Medicare uses coordination of benefits to determine which insurance plan will pay first. When caring for someone who has multiple types of coverage, it’s best to reach out to the Benefits Coordination & Recovery Center (1-855-798-2627) to confirm how Medicare will work with any other coverage plans in place.
What Medicare prescription drug plans cover
All Medicare prescription drug plans have a formulary list of prescription drugs that are covered by the plan. There are both generic and brand name prescription drugs on the formulary list. To understand which drugs a plan will cover, you will want to contact the plan.
The following are common rules that may apply to prior authorization, quantity amounts, and step therapy:
- Prior authorization – In these cases, the beneficiary and/or doctor must contact the plan before certain prescriptions can be filled.
- Quantity limits – Some drugs are limited on how many pills or doses that can be given at a time.
- Step therapy – In these situations, the beneficiary must try one or more similar, lower-cost drugs before the plan will cover the drug prescribed.
If the beneficiary’s doctor believes that any of the coverage rules should be waived, an exception can be requested.
How to choose a prescription drug plan
It’s best to take the time and choose a plan that meets all the beneficiary’s needs. The following things can be done to help make the best decision when choosing a prescription drug plan for a loved one:
- Speak with the Medicare plan
- Call 1-800-Medicare (1-800-633-4227)
- Review Your Guide to Medicare Prescription Drug Coverage, which can be found on www.medicare.gov
- Contact the State Health Insurance Assistance Program (SHIP) in your state
- Refer to the Medicare & You handbook, which is mailed to all Medicare recipients each fall
Continuing care options
Sometimes illness or injury requires ongoing care. Care can range from home care, nursing home care, and hospice care. There are a variety of care options available and Medicare can cover some of these costs.
Home health care
After hospitalization or illness treatment, a beneficiary may need short term care at home. Home care can include nursing care, physical therapy, occupational therapy, and speech therapy. In some cases these services may include medical equipment like wheelchairs or hospital beds. With Medicare, the home health benefit can be used if all of these conditions are met:
- The doctor determines that medical care at home is needed
- It is necessary to receive one or more of the following services:
- Physical therapy
- Speech-language pathology
- Intermittent skilled nursing care
- Continued occupational therapy
- The home health agency must be Medicare-certified
- The beneficiary must be homebound or unable to leave home alone
To confirm eligibility for Medicare’s home health-care services, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
In cases where the doctor decides that home health care is needed, you can choose an agency from the Medicare certified list. To find an agency, it’s best to ask the doctor or hospital. You can also speak with a senior referral service for a recommendation. These agencies are certified because there are federal health and safety requirements that need to be met. Medicare has created a Home Health Compare tool to help caregivers and beneficiaries compare home health agencies.
The following are questions you should ask when considering a home health agency:
- Is the agency Medicare-certified?
- How long has the agency been open?
- What services does the agency provide?
- Can you give an example of an emergency and how it’s addressed?
- What are the hours of the staff?
- What are the costs?
- What is communication like with the doctor?
Nursing homes and housing options
In some cases, family members and caregivers along with a doctor’s recommendation may decide that full time care outside the home is needed. There are various options available for care. The following provides a description of each type of care option.
Facility Description Independent Living Independent living, but offering meals, social and recreational activities. Assisted Living Residential homes offering services that include limited assistance and supervision with daily living tasks, like cooking and medication management. Continuing Care Retirement Communities (CCRC) Housing community that provides different levels of care based on residents’ needs. Adult Day Care Daily, structured activities, and rehabilitation services in a protective environment. Care is provided during the day, and individuals go home in the evening. Custodial Care Assistance with daily activities like bathing, eating, and dressing. Skilled Nursing Facilities 24-hour supervision and medical and rehabilitative services for those requiring high-level care. Medicare covers this after a three day qualifying hospital stay. Nursing Home Permanent residences for those who are too frail or sick to live at home. These residents usually require daily assistance and receive help with dressing, bathing, and using the bathroom.
You can start your nursing home care search at www.medicare.gov. You can also compare Nursing homes, using the comparison tool provided by Medicare. The following are questions to ask when considering a nursing home. You may want to make surprise visits to verify conditions at the nursing home.
- Is the nursing home Medicare- or Medicaid-certified?
- Does the nursing home have the level of care needed and is a bed available?
- Is the nursing home free from odors?
- Is the nursing home clean?
- Does the nursing home meet religious, cultural, and language needs?
- Are residents clean, groomed, and appropriately dressed?
- Are staff background checks conducted?
- How does the staff interact with residents?
- Are the nursing home and the administrator licensed?
This type of care can quickly become very expensive. Many types of health insurance do not cover nursing homes. Most people who are in nursing homes are paying out of their own pocket. Generally Medicare doesn’t cover nursing home care.
Medicaid may pay the long-term care costs for individuals who meet the eligibility requirements. This is a state and federally funded program that pays most nursing home costs for people with limited income. Medicaid will pay for nursing home care only when provided in a Medicaid-certified facility.
For information about Medicaid eligibility, call the state specific Medical Assistance (Medicaid) Office, or you can visit www.medicare.gov for more information.
Those who may be terminally ill will want to look into hospice care. This type of care includes treatment to ease the symptoms and keep the person comfortable. In these cases, the goal is to provide end of life care, not to cure illness. The various types of care we reviewed earlier could be part of the hospice care that the individual receives. Hospice care can be given in the comfort of ones own home with their family by their side. Medicare’s hospice benefit offers support and comfort to beneficiaries who are dying, and includes services not usually covered by Medicare. Medicare also pays for inpatient respite care so the usual caregiver be given time to rest.
For hospice care, the beneficiary must have Medicare Part A (hospital insurance) in addition to the following:
- The doctor and hospice must confirm that the beneficiary is terminally ill and has six months or less to live.
- The beneficiary must sign a statement selecting hospice care as oppose to routine care benefits.
- The beneficiary must be receiving care from a Medicare-approved hospice program.
Treatments for terminal illness cures are not covered by Medicare hospice benefits. If health improves or the illness goes into remission, he or she always has the right to no longer receive hospice care and go back to the original Medicare health plan.
To locate a hospice program you can contact 1-800-Medicare (1-800-633-4227) or reach out to your local State Hospice Organization. You can also use the Hospice comparison tool to help select a hospice.
The information provided here is not to be substituted for medical advice; this is for information purposes only. Always consult with your doctor and medical provider when making health related decisions. It’s important to note that Medicare rules and guidelines are subject to change so it’s always best to verify information with your Medicare plan.