Presentation on theme: "DRAFT Promotional Copy for NNSDO Financing Health Care for Older Adults."— Presentation transcript:
DRAFT Promotional Copy for NNSDO Financing Health Care for Older Adults
Objectives Summarize relevant facts and general guidelines of Medicare, Medicaid, and the Older Americans Act. Differentiate among Medicare, Medicaid, and the Older Americans Act and discuss the essential elements of each and their relevance to care of older adults.
Objectives Discuss the financing for primary care, hospital care, home care, hospice care, and nursing home care of older adults. Explain how financing drives choice of health-care plan, setting, and extent of care. Identify research priorities related to quality and cost of care for older adults.
Medicare Enacted into law in 1965 (title XVIII of the Social Security Act) – The Health Insurance for the Aged and Disabled Act. Foundation for retirees’ protection against heavy medical expenses. Administered by the Centers for Medicare and Medicaid Services (CMS) formerly the HCFA
Medicare Part A. Hospitalization Insurance (HI) How financed? Social Security or Railroad Retirement funding Inpatient hospitalization, limited care in skilled nursing facility, home health services, hospice care, therapy services
Medicare Part B. Supplemental Medical Insurance (SMI) How financed? Deducted from Social Security check Physician services, hospital services, diagnostic services, outpatient rehab services, vaccination, dialysis supplies and support services, rural health clinic services, home health services
Medicaid Title XIX of the Social Security Act enacted in 1965 Federal / State entitlement program Pays for medical assistance of certain individuals and families with low income and resources Test for eligibility: low income
Medicaid: State responsibilities Establishes its own eligibility standards Determines type, amount, duration, and scope of services Sets rate of payment for services Administers its own program
Older Americans Act (OAA) Created on July 14, 1965 Takes responsibility for well-being of older adult citizens Expanded opportunities to enrich their lives Administered by State and Area Agencies on Aging
Older Americans Act (OAA) Expanded opportunities to enrich their lives Adequate income in retirement Best possible physical and mental health Suitable housing, independently selected, affordable Full restorative services Opportunity for employment
Older Americans Act (OAA) Expanded opportunities to enrich their lives Retirement in health, honor, dignity Pursuit of meaningful activity Efficient community services Immediate benefit from proven research knowledge Freedom, independence, and free exercise of individual initiative in planning and managing their own lives
OAA: Title III Grants for State and Community Programs on Aging Access services: transportation, outreach, and case management In-home services: homemaker, visiting and telephone reassurance, chore and supportive services Legal assistance: financial, insurance, tax counseling, guardianship proceedings Supportive services and Senior Centers
OAA: Title III Grants for State and Community Programs on Aging Congregate and home delivered nutritional services Disease prevention and health promotion services National Family Caregiver Support Program Training, Research, and Discretionary Projects
OAA: Title III Grants for State and Community Programs on Aging Community Service employment for Older Americans Grants for Native Americans Vulnerable Elder Rights Protection Activities: Ombudsman Program Prevention of Elder Abuse, Neglect, and Exploitation Legal Assistance Development Program
Elements MEDICAREMEDICAIDAGENCIES ON AGING Source of financing Federal through separate payroll contributions paid by employees, employers, and self-employed persons StatesFederal Age Eligibility 65 and older (covers some people less than 65 who are disabled) All agesEntitlement $ Eligibility Entitlement, that is almost everyone 65+ irrespective of income Low income and resources 65 and older Administration Administrator of the Centers for Medicare and Medicaid Services (CMS); Voluntary insurance organizations States, under broad federal guidelines Area Agencies on Aging
Primary Care Services Medicare is primary payer for primary care services: Physicians and Nurse Practitioners / Clinical Nurse Specialists Fee-for-service (FFS) option Covers office visits, ambulance services, ER care, visits in the home, hospital, nursing home Preventive services: immunizations, mammography, prostate cancer screening, colorectal cancer screening, glaucoma screening
Hospital Payment Medicare is primary payer for in-hospital and physician / nurse practitioner services Medicare deductible: does not fully cover MD and other services Most older adults carry supplemental insurance (MediGap insurance)
Home Care Medicare is primary payer for short-term skilled nursing care in the home (typically 3 months or less) Rehabilitation services, wound care, catheter care, teaching patient and family to give injections Covers RN, PT, OT, Home health aides, durable medical equipment,
Home Care Medicaid pays for long-term home health care Type and amount of care available varies from state to state Medicaid-covered services Home Health Attendants Physician, Nurse Practitioner Professional Nursing Home visits
Nursing Home Medicare pays for short-term (100 days or less) skilled nursing home care – medically unstable. Skilled care: rehab services, wound and catheter care, teaching patient and family to give injections Older adult must be able to participate in rehab to qualify for Medicare coverage
Nursing Home Medicaid pays for long-term nursing home health care Care varies from state to state Approximately 40% of care is paid out- of-pocket by older adult and family
Hospice Care Medicare is primary payer Eligibility is based on anticipated death within 6 months Hospice can be delivered at home, in a hospital, nursing home, or hospice facility Aggressive pain and symptom management Cancer, heart disease, chronic obstructive pulmonary disease, dementia
Social Services Families are primary source of social services for older adults Older Americans Act (OAA) is primary source of publicly-funded social services. OAA is administered by the Area Agencies on Aging (AAA) Services: congregate meals, meals-on- wheels, transportation, and ombudsman services
Limitations in Primary Care Services Low Medicare reimbursement for geriatric practitioners and geriatricians No reimbursement for geriatric interdisciplinary team activities Medicaid is “means-tested” – older adults must meet state income limits to qualify
Limitations in Hospital Payment Some older adults still require acute care services at the time of discharge. Whether and where older adults receive these acute care services influences short- and long-term recovery
Limitations in Home Care Services Medicare reimburses only for skilled care. Low reimbursement for geriatric nurse practitioners and geriatricians. Older adults must meet state income limits in order to qualify for Medicaid reimbursed home care services.
Limitations in Nursing Home Payment Older adults must meet income limits in order to qualify for Medicaid- reimbursed long-term care nursing home placement. Frequent and often unnecessary transfer of nursing home residents from the nursing home to the hospital.
Limitations in Hospice Payments Tends to focus on cancer rather than other diagnoses. Reluctance to access hospice in a timely manner due to Hospice criteria On average, older adults receive Medicare hospice for only a few days prior to death.
Limitations in Social Services Payment Funding is very limited for social services under the Older Americans Act. Older adults may qualify for services, but these services may not be available.
Research Priorities Cost savings realized through health promotion activities Home care quality and cost versus nursing home care quality and cost Planning for long-term care – attitudes of aging baby boomers about providing financially for long term care.
Summary Summarized facts / guidelines of Medicare, Medicaid, and the Older Americans Act Financing for primary care, hospital care, home care, nursing home care, hospice, and social services Limitations of financing health care Research priorities