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Navigating the Complex Care System Models and Costs 1.

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Presentation on theme: "Navigating the Complex Care System Models and Costs 1."— Presentation transcript:

1 Navigating the Complex Care System Models and Costs 1

2 Adult Day Health Center The goals of the programs are to delay or prevent institutionalization by providing alternative care, to enhance self-esteem and to encourage socialization. The medical model of adult day health care means that there is a full time RN who can monitor medications, blood pressure, interface with the participants physician, there is a MSW social worker and certified Activity professionals all of whom interact with the participants. 2

3 Adult Day Health Centers, Who Pays? Services are covered under: Long term care insurance Veterans benefits Medicaid Waiver Private pay, with rates varying between $60 to $90/day 3

4 Assisted Living Facilities Assisted living is a care option that combines housing, support services and health care for individuals who require assistance with daily activities such as meals, medication management, bathing, dressing and transportation. Some residents may have memory disorders, need help with mobility, or be incontinent. Residents are assessed upon admission, and an Individualized Service Plan is developed. The monthly fee is based upon how much help a person needs. 4

5 Assisted Living Facilities, Who Pays? Monthly cost: $3,000 on the low end and up to $7,000 on the higher end depending upon how much care/assistance a person needs. Sources of Payment: Private pay Long term Care Insurance [the amount depends upon individual policies] Auxiliary Grants, a form of Medicaid for people making under $1,400/month. Few facilities accept this form of payment as it is too low to cover the cost. MEDICARE DOES NOT PAY FOR ASSISTED LIVING 5

6 Nursing and Rehabilitation Care Nursing Care by definition is administered under the direction of a physician. Many people are permanent residents because they are too sick/frail to return home. Sub-acute & rehabilitation services, for shorter stays, often after being hospitalized. These services include physical, occupational, and speech therapy, wound care and other skilled services that require a licensed person to perform The cost of nursing home care is $75,000- $80,000/year 6

7 Nursing and Rehabilitation Care, Who Pays? Personal Resources: about half of all nursing home residents pay nursing home costs out of their own savings. After these savings and other resources are spent, many people who stay in nursing homes for long periods eventually become eligible for Medicaid. Managed Care Plans: a managed care plan will not help pay for care unless the nursing home has a contract with the managed care plan. You need to check to see if the home is approved by your plan. Long Term Care Insurance policies often cover up to a certain amount per day (this differs by policy) for a defined amount of time (this differs by policy). 7

8 Nursing and Rehabilitation Care, Who Pays? Medicare: under certain limited conditions, Medicare will pay some nursing home costs for those who require skilled nursing or rehabilitation services. You must receive the services from a Medicare certified skilled nursing home after a 3-day hospital stay. Medicare Supplemental Insurance: this is private insurance. It's often called Medigap because it helps pay for gaps in Medicare coverage such as deductibles and co-insurances. Most plans will help pay for skilled nursing care, but only when that care is covered by Medicare. Medicaid is a State and Federal program that will pay most nursing home costs for people with limited income and assets. Medicaid will pay only for nursing home care provided in a facility certified by the government to provide service to Medicaid recipients. 8

9 Continuing Care Retirement Communities (CCRCs) Part independent living, part assisted living and part skilled nursing home, CCRCs offer a tiered approach to accommodate residents changing needs. Upon entering, healthy adults can reside independently in single- family homes, apartments or condominiums. When assistance becomes necessary, they can move into assisted living or nursing care facilities. These communities give older adults the option to live in one location for the duration of their life, with much of their future care already figured out. This can provide a great level of comfort to the senior and the family. 9

10 CCRCs, Who Pays? CCRCs require an entrance fee as well as monthly charges. Entrance fees can range from $100,000 to $1 million. Monthly charges can range from $3,000 to $5,000, but may increase as needs change. These fees are dependent on a variety of factors including the health of the person, the type of housing they choose, whether they rent or buy, and the type of service contract. Additional fees may be incurred for other options including housekeeping, meal service, transportation and social activities 10

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