Paying for Care for Elderly Loved Ones
One of the most confusing aspects of helping care for an aging relative can be understanding how to pay for the care they need. There is a misconception that a combination of Social Security and Medicare will provide coverage for most needs. Unfortunately, this is not the case. We will discuss what Social Security and Medicare “covers” and what it doesn’t. In addition, we will discuss the basic categories of care most often needed by elders and payment options available.
While Medicare provides a significant portion of the healthcare needs of elders, it is limited in coverage to specific aspects of healthcare.
What is NOT covered by any form of Medicare-based insurance includes the following:
Assisted living including memory care
Nursing Homes – see below that is covered by Medicaid within certain financial requirements
Home care other than immediately post hospitalization or illness; NO maintenance
Private duty, ongoing services of care aid at home
Transportation
Some medical equipment and supplies are covered, and some aren’t
In some cases, privately purchased “long-term care” insurance will provide coverage for some of these needs. Policies vary greatly so you will need to review it carefully.
Medicare (Part A, B, C, D)
The main social service program provides certain healthcare services for elder Americans. Anyone who paid – or was married to someone who paid - Medicare taxes during their working years are eligible and does not pay premiums for Medicare Part A once they're 65 years old. There are premiums for other parts of Medicare B, C, and D as explained below.
Medicare Part A
Hospital care coverage - pays for care at a hospital, skilled nursing facility, or nursing home, and for limited home health services immediately after the acute care event or other acute illness.
Medicare Part B
Out-patient care from a provider who “accepts Medicare”
This is care that does not require you to stay away from home overnight
Most, but not all, physician groups and major health systems accept Medicare
Types of care included:
Medically necessary e.g., most out-patient care to diagnose and treat chronic and acute illnesses.
Preventive services e.g., Medicare Annual Wellness, flu vaccine, colonoscopy
WITH STIPULATIONS Part B may cover things such as:
Ambulance services
Durable medical equipment
Medicare Part C
This is care provided by a PRIVATE insurance company authorized by the US Government. They provide BOTH Medicare Part A and Part B services of a similar scope to “traditional Medicare” under the name “Medicare Advantage Plans.”
Medicare Part D
Medicare prescription drug benefit covering self-administered prescription drugs.
This is an additional, optional election that must be made during the “open enrollment” period as basic insurance is being chosen.
Useful Links for Understanding and Navigating Medicare
Medicare.gov/HealthinAging.com sheets
Medicaid
Medicaid is a joint federal and state program that provides certain healthcare services for elders. The most common use is for long-term care aka “nursing home” care for elders with significant frailty. Unlike Medicare, which is provided to all seniors, Medicaid has financial eligibility for its coverage. For elders with personal funds there is a requirement to “spend down” personal assets to a specified level (which varies by state) before they will be eligible for Medicaid coverage.
Program of All Inclusive Care for the Elderly
Though not available everywhere, the program called “PACE” is a type of insurance coverage for elders who are eligible for both Medicare and Medicaid. In these uniquely comprehensive programs frail elders who need daily support are provided an adult day like environment during weekdays. Medical care comes to the elder via the interdisciplinary team at the PACE site.
The National PACE Association operates a “locator” map to identify PACE sites near you.
To be eligible for PACE, an individual must:
Be 55 years of age or older
Live within the defined service area of the PACE Center
Meet medical eligibility requirements as determined by CARES
Be able to live safely in the community
Be dually eligible for Medicaid and Medicare, or Medicaid only. There is also a private pay option with PACE, however this is not regulated by the State.
Navigating Insurance Options
A terrific resource in the state of Florida pairs trained volunteers with elders to provide an unbiased and knowledgeable review of the range of insurance options available to them. You can trust these volunteers who undergo careful training and education about the options. One-on-one counseling sessions are arranged for in-person or virtual sessions. For more information visit Florida Shine.
