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

Questions?