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In This Chapter

^ Making sure your Part D coverage works in a nursing home ^ Changing Part D plans if you need to ^ Finding sources of help

7he phrase Long-term care Covers several different living situations. It includes everything from staying in a nursing home through being in various kinds of assisted living facilities (where people can live independently but with access to support services) to living at home with support from personal caregivers and community services.

In most of these situations, the rules for Medicare Part D drug coverage are no different than those described in the rest of this book. But this chapter focuses on some special protections and rights — and things to consider — in regard to Part D for people in two types of long-term care. If one of the following situations applies to you, then you can’t afford to skip this chapter:

You’re living temporarily or permanently in a nursing home or another institutional setting (such as a rehabilitation hospital or unit, long-term care hospital, or psychiatric hospital or unit) that offers round-the-clock nursing care and help with daily activities.

You’re staying in a skilled nursing facility (which may be located in a nursing home or a hospital) for needed care after an illness or injury.

For all these situations, I use the term Nursing home Throughout this chapter. And I need to define another term here, too. That term is You. In this chapter I address "you" (the patient), while understanding that many people going into nursing homes are too frail or sick to be able to cope with Part D issues. So when I say "you," I expect that, in many cases, you (the reader) will actually be a family member, friend, or other personal caregiver helping a patient who’s in a nursing home.

In this chapter, I explain special Part D rules and rights that apply to people in nursing homes when paying for prescriptions or changing plans. I describe a special kind of Medicare health plan that focuses on the needs of people in nursing homes, and another Medicare program that provides comprehensive care designed to keep people out of nursing homes for as long as possible. Finally, I suggest sources of help.

Reviewing Your Drug Coverage When You Enter a Nursing Home

When you first go into a nursing home, it’s likely that the last thing on your mind (or your caregiver’s) is whether you need to do anything about your Part D plan. You have too many other practical and perhaps emotional issues to think about. And if you’re already in a plan, why worry?

Well, you need to consider a few points about Part D, even at this difficult time. In the following sections, I explain why you need to find out how your meds are covered in the nursing home and why, in some circumstances, it may be wise or even necessary to change from your current Part D plan to another.

Understanding how your drugs will be covered

In most cases, while you’re in a nursing home, your meds are covered under the usual conditions of your Medicare Part D plan (or under any alternative drug coverage you have, such as an employer or union health insurance plan; see Chapter 6 for details about different types of drug coverage). The following sections note three exceptions.

Lf you receive the Medicare skilled nursing facility benefit

If you’re receiving the Medicare skilled nursing facility benefit, your prescription drugs are covered under Medicare Part A (hospital insurance) for a certain amount of time, and Your Part D plan isn’t involved.

Many people don’t realize that Medicare does Not Usually cover what the agency calls Custodial care In a nursing home. That means room and board, nursing care, and help with daily living activities. But the Medicare skilled nursing facility (SNF) benefit is an exception. To qualify, you need to be enrolled in Medicare Part A. You must also have spent at least three days as an inpatient in a hospital And Need skilled care for nursing and rehabilitation services related to the illness or injury that put you into the hospital. A

Physician must refer you for SNF care under this benefit and certify that you need it as a matter of medical necessity. For example, a need for intravenous injections and physical therapy are reasons for this kind of continuing care.

If you qualify for this benefit, Medicare Part A covers all of your care in a Medicare-certified skilled nursing facility (either in a nursing home or hospital) for up to 100 days.

For the first 20 days, Medicare Part A pays for all of your care needs — including the cost of your room and board, help with daily living activities, and prescription drugs — and you pay nothing.

From 21 to 100 days in the facility, you’re responsible for a co-pay (up to $128 a day in 2008).

JjttNG/ If you’re still in the SNF after the 100 days are up, you’ll be responsible for all 4^»~3£\ costs, and Medicare pays nothing. (However, a Different Illness or injury that requires skilled care after another three-day stay in the hospital would qualify you for another 100-day benefit period.) So from day 101, if you have Part D drug coverage, you must then get your prescription drugs through your Part D plan. Make sure, well before the SNF benefit runs out, that the plan covers your prescriptions (as explained in the later section "Asking important coverage questions on Day One") to prevent any interruption of treatment.

&UJG/ Just because the SNF benefit lasts for up to 100 days doesn’t mean you can

Choose to stay in the facility that long. Your continuing eligibility to stay there is reviewed regularly and depends on whether your physician and/or other medical professionals (such as physical therapists) consider that further days or weeks at the facility will result in an improvement of your condition. So if your condition reaches a Plateau — a point when the illness or injury isn’t expected to get any better — you lose your eligibility for the SNF benefit and must leave the facility, even if you don’t feel better and actually need continuing care.

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If you receive full Medicaid benefits

If your state pays for your medical benefits under the Medicaid program and you’re enrolled in Medicare Part D for your prescription drug coverage, you’re probably already receiving Part D’s Extra Help benefit (as explained in Chapter 5) and paying small co-pays for your meds. After a month in the nursing home, though, you should no longer pay Anything For your meds for the rest of your stay. (In the event that you continue to be charged co-pays, call Medicare at 800-633-4227 or call your plan to get it to correct the mistake. Any undue payments you’ve made must be refunded to you.)

Medicaid also pays most of the costs of Medicaid-certified nursing homes for people with low incomes and few resources. Eligibility varies from state to state. Many patients who enter nursing homes pay the costs themselves or through long-term care insurance, but they become eligible for Medicaid when their savings are used up (or their insurance runs out and they have no

Savings to fall back on). In this situation, you receive a small allowance for personal needs. You’re not expected to pay for prescription drugs out of this allowance — again, your Part D plan must not charge you anything for the drugs it covers. If the plan doesn’t cover all the drugs you need, Medicaid may cover them instead (as explained in Chapter 5).

Ensuring all of your meds are covered when you enter a nursing home

Very often, people go into nursing homes after being in the hospital, where they’re prescribed more or different drugs than they were taking before being hospitalized. For this reason, and so that your treatment isn’t interrupted, your Part D plan must cover all the meds that you’re taking when you first enter the nursing home for at least 90 days — even if the plan normally doesn’t cover some of these drugs or restricts access to them. Some plans extend this transitional period for up to 180 days after their enrollees go into nursing homes. Your plan can tell you how long the transitional period lasts.

Asking important coverage questions on Day One

Physicians who care for people in nursing homes say there are good reasons for patients (or their caregivers) to consider their Part D plan carefully and find out whether it’ll continue to work for them in these changed circumstances As soon as possible after admission, or even before. "Ideally," one physician told me, "they should do this on Day One." These are the questions to ask and why you should ask them:

Are any of the pharmacies that the nursing home uses also in my Part D plan’s pharmacy network? Nursing homes use special long-term care (LTC) pharmacies that dispense prescriptions in special packages — the drugs come in single doses, individually sealed, instead of the usual containers. This is for hygiene and safety reasons in a setting where nurses administer a great many different drugs to many patients. LTC pharmacies may be large companies that supply only nursing homes and other LTC facilities or, in rural areas, local retail pharmacies that can supply properly sealed medicines. All Part D plans must include LTC pharmacies in their networks. But if the ones your nursing home uses are Not In your plan’s network, the plan most likely won’t cover your drugs. The nursing home won’t pay for your meds if your plan doesn’t cover them, even if you can’t afford them.

Does my Part D plan cover the medicines that I’m taking Now? As

Explained earlier in this chapter, your Part D plan must cover all the drugs you’re taking when you first enter the nursing home for at least 90 days. But it’s wise to check whether the plan will continue to cover your prescriptions (especially if they’re new ones) after this transitional supply has run out — and, if necessary, take steps to avoid having to pay full price for them at that time.

You can ask the nursing home administrator or social worker for the names of the long-term care pharmacies it uses; then call your plan and ask whether those pharmacies are in your plan’s network. If you’re not sure, the administrator or social worker can also tell you whether Medicare Part A is covering your stay (and your drugs) under the skilled nursing facility benefit. (I explain this benefit earlier in this chapter.) To find out whether your Part D plan covers your new prescriptions or imposes any conditions restricting your access to them (as explained in Chapter 4) — you should call the plan.

If you’re Not Covered by the Part A skilled nursing benefit (or if it’s run out), you may be facing at least one situation that requires action:

The LTC pharmacy isn’t in your Part D plan’s network. You need to change your plan, as explained in the next section.

Your plan doesn’t cover some or all of the drugs you now need or restricts immediate access to them. You can ask your attending doctor whether any alternative drugs your plan does cover would work as well for you (as explained in Chapters 4 and 16). Or you can ask your attending doctor to request an exception to the plan’s policy (see Chapter 4). In this case, it’s important for the doctor to explain to the plan representative that you’re in a nursing home and to fully describe why this particular drug is medically necessary for you and why an alternative covered by your plan wouldn’t work as well or could cause additional medical problems. Other ways of dealing with this situation may be

• Finding out whether Medicaid (if you’re enrolled in the program) will pay for drugs your plan doesn’t cover. Ask the nursing home social worker or a counselor at your State Health Insurance Assistance Program (SHIP) to help you. (For your local SHIP’s contact information, see Appendix B.)

• Switching to a Part D plan that covers your drugs or imposes no, or fewer, restrictions, as explained in the next section.

Switching to Another Plan

In general, the process of switching plans when you’re in a nursing home is the same as it is for anybody in Part D (see Chapter 17). But when you enter a nursing home, you immediately have rights that most other folks don’t have. In this section, I explain those rights and some additional tips. I also describe two special types of Medicare health plans that are available in some areas: Special Needs Plans and PACE plans.

Knowing your rights for changing plans

You have an absolute right to change your Part D plan, if you wish, when you enter or leave a nursing home, and at any time during your stay there. In other words, you don’t have to wait until the general enrollment period at the end of the year. Instead, you automatically receive a special enrollment period (SEP) to make the change. You don’t have to apply for this SEP or disenroll from your current plan — just enroll in a new plan, explaining the situation.

Recognize, too, that this right to switch plans applies if you’re in any Medicare – or Medicaid-certified Institutional facility — an umbrella term that sounds grim but actually comprises nursing homes, skilled nursing facilities, rehabilitation hospitals or units, long-term care hospitals, psychiatric hospitals or units, or intermediate care facilities for the mentally retarded.

Table 18-1 shows how often you can change Part D plans when you enter, live in, or leave any of the preceding facilities and when your new coverage starts.

Choosing and enrolling

In a new Part D plan

Having the right to switch to a different plan doesn’t overcome the fact that it’s a hassle if you need to do so — especially when you, the patient, are too frail or sick to go through the process. In such circumstances, you’d think that the simplest way would be to ask the nursing home staff or your attending physician to point you to the plan they think would suit you best. But Medicare Prohibits These professionals from doing so. This rule is intended to protect patients and prevent the possibility of doctors and nursing facilities receiving financial kickbacks for steering patients to a particular Part D plan.

But consumer and patient groups, long-term care physicians, and pharmacists point out that the rule lays a burden on many patients at a time when they are at their most vulnerable and unable to cope with it.

So if you’re a family member, friend, or personal caregiver of the patient, you’re likely to be the one helping to choose his new Part D plan. You may be able to choose a new plan by using Medicare’s online Prescription Drug Plan Finder, following the guidance I give in Chapter 10. If you don’t want to go online to compare drug plans, you can call Medicare or any of the other sources of help listed in Chapter 10.

Although nursing home staff, physicians, and pharmacists are banned from steering anybody to any one plan, they may be willing to do an objective search on the Medicare plan finder to identify the three or four plans that would suit the patient’s needs best (according to the drugs needed), and then you can make a final choice from that shortlist.

After you’ve found a suitable plan, the patient needs to be enrolled in it, and he must sign the enrollment application. Or, if the patient is incapable of signing, you (as caregiver) may be able to do so. If you already have Durable power of attorney — the right to make medical and financial decisions on the patient’s behalf, according to the laws of your state — you can sign the enrollment form as explained in Chapter 12.

Checking out two alternative plan options

Two types of Medicare health plans are specially designed for people who are either in nursing homes or are eligible for nursing home care. These plans may be worth considering, according to your circumstances and preferences, if the plans are available in your area.

Special Needs Plans

Special Needs Plans (SNPs) are Medicare private health plans (usually HMOs or PPOs). Each one serves the specific needs of one group of people in three categories (see Chapter 9). One of these categories is for people who have been (or expect to be) in long-term care facilities, such as nursing homes or other institutions, for 90 days or longer.

SNPs, which came into existence in 2004, are still somewhat experimental. In 2008, Congress authorized them to continue through 2010, but also barred any new ones from setting up in 2009 and 2010 until Congress has again reviewed the program and decided whether to continue it. Meanwhile, existing SNPs may accept more enrollees. Only about half of Medicare beneficiaries have access to SNPs that serve nursing home residents.

SNPs for people in nursing homes and other types of long-term care (which include assisted living facilities) are supposed to offer ways to coordinate care and services. For example, an SNP may provide a case worker or care

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Manager who helps patients coordinate Medicare and Medicaid benefits, links patients with needed community services, advises on managing health conditions, and maybe helps solve problems with drug coverage. These services, and their quality, vary a great deal among different plans. By 2010 all SNPs must provide a care management plan for each enrollee.

If you’re considering joining an SNP for nursing home patients, find out not only its costs and benefits, but whether it covers the providers that you prefer — all the factors relating to Medicare health plans that I cover in Chapter 9. The SNP should cover most of the meds commonly used by nursing home patients. But it’ll still have a formulary, so check that it covers the drugs you need.

You can enroll in this type of SNP (if one is available to you) when you enter a nursing home, regardless of the time of year. Your coverage starts on the first day of the month after you enroll. But if your special needs status changes so that you’re no longer eligible for this kind of plan, you can switch to another Medicare health plan with drug coverage or to traditional Medicare and a stand-alone drug plan. This SEP begins in the month your special needs status changes and ends up to three months after you’re disenrolled from the SNP.

You can find out whether there’s an SNP for nursing homes in your area by calling Medicare (800-633-4227) or by going to its online plan finder at www. Medicare. gov. You may also want to take advice from your State Health Insurance Assistance Program (SHIP), as explained in the later section "Getting Help for Yourself or Your Loved One."

Programs of All-Inclusive Care for the Elderly

Programs of All-Inclusive Care for the Elderly (PACE) is a Medicare program that helps people who’d otherwise need nursing home care to continue living in their own homes or with their families in the community for as long as possible. It provides comprehensive medical and social services — including home care, day care, physical therapy, dentistry, meals, social work counseling, transportation, and many other services. It also provides hospital and nursing home care should you need it. You can’t choose your own doctors in a PACE plan. Instead, you’re assigned a primary care physician who is one of a team of healthcare professionals working with you and your family to help maintain your overall health. The team also provides support to your care-givers. PACE programs include Medicare Part D drug coverage, so you don’t have to join a separate drug plan.

You can join a PACE program if You’re 55 or older

You’re certified by your state as being eligible for a nursing home level of care, after an assessment by the PACE plan’s care team

A program serves the area where you live and is accepting new enrollees

You’re enrolled in Medicare Or Medicaid

You’re able to live safely in the community with the help of PACE

PACE has no deductibles or co-payments for any service, care, or prescription drug approved by your care team. Other costs depend on your situation:

I If you qualify for Medicaid, you pay a small monthly payment — and nothing for long-term care if you need it. The PACE plan determines the amount of the payment.

I If you don’t qualify for Medicaid, you pay a monthly premium to cover the long-term care part of the PACE benefit and also a monthly premium for Medicare Part D drugs, in each case paying what the plan requires.

If you’re eligible for an available PACE, you can join it at any time. If you’re enrolled in Medicare, you get a special enrollment period to leave traditional Medicare or a Medicare private health plan to join the program. (You can’t be in either of these programs at the same time as being enrolled in a PACE.) Also, you can leave a PACE any time you want to switch to traditional Medicare or a Medicare health plan.

To find out whether a PACE exists in your area, call Medicare (800-633-4227) or go to Www. cms. hhs. gov/PACE/LPPO/list. asp. If you’re interested in joining it, contact the plan to arrange a home visit with you or your caregiver, or a visit to the PACE center. The plan will schedule a meeting between you and its care team for a medical and social assessment that determines your eligibility for the program. For more on how PACE works, go to the National PACE Association’s Web site at Www. npaonline. org.

Getting Help for Yourself or Your Loved One

Don’t hesitate to get help for yourself or your loved one; some problems you just can’t cope with on your own. Here are some resources:

Your State Health Insurance Assistance Program (SHIP): Whenever you need information or help with a problem with Medicare or Medicaid, including Part D and long-term care issues, your best bet by far is to phone your local SHIP immediately. This way, you get free, personal counseling from experts familiar with your area. For the phone number of your state SHIP, go to Appendix B.

Medicare long-term care information: Medicare’s Web site (www. Medicare. gov) provides detailed information on different types of long-term care. On the home page, click "Long Term Care." The site also has useful info on all nursing homes in the country that are certified by Medicare or Medicaid, including details of how well (or not) they perform. Click "Nursing Home Compare." You can get the same info by calling the Medicare help line at 800-633-4227 and asking the customer service rep to search for details of the nursing homes you’re interested in and send you printouts.

Your state long-term care ombudsman: This is the person to contact if you have complaints or concerns about the care you receive in an LTC facility or are trying to find a facility. The ombudsman is trained to troubleshoot problems on behalf of people in nursing homes, board-and-care homes, and assisted living, and acts as their advocate. Every state, plus the District of Columbia, Puerto Rico, and Guam, has an LTC ombudsman. To find the name and phone number of the ombudsman for your area, go to the National Long-Term Care Ombudsman Resource Center’s Web site at Www. ltcombudsman. org. Or call your state Office of Aging (in the state pages of the telephone directory) for the number.

Your Area Agency on Aging: These public services are provided by the federal Administration on Aging to help older people maintain their independence and remain in their community. Each agency acts as a resource center for linking seniors and caregivers with local services and support groups. Visit the national Web site at Www. aoa. gov/ eldfam/eldfam. aspx or call your local Agency on Aging at the number in the state pages of your phone book.

Family Caregiver Alliance: This long-established organization offers programs at the national, state, and local levels to support families who provide long-term care at home for relatives or friends. Among FCA’s numerous services, check out its Family Caregiver Locator to find many resources for caregivers in every state and its Caregiver Toolkit, a large resource of practical information. Visit its Web site at Www. caregiver.

Org or call 800-445-8106.

National Family Caregivers Association: This group supports, educates, and acts as a national advocate for more than 50 million Americans who care for sick or disabled elderly relatives. It also offers local training for improving at-home caregiving skills. Visit its Web site at www. Nfcacares. org or call 800-896-3650.

AARP’s Caregiver Web site: The world’s largest nonprofit organization for people age 50 and over, AARP maintains a Web site that provides practical information for caregivers of all kinds. Go here for an estimate of costs for nursing homes, assisted living facilities, home health aides, and adult day care in your state. Among many articles and tools, check out "Prepare to Care," a planning guide for new caregivers, and "LongDistance Care-Giving," on what to do if a loved one far away needs help. Visit the Web site at Www. aarp. org/families/caregiving.

Chapter 19