Preventative services including doctor’s visits, surgeries, medical equipment, and outpatient hospital visits. See below which services are covered or free and which ones require you to pay a 20% Co-insurance. 

20% CO-INSURANCE FEE

• Ambulance Service
• Abdominal Aortic Aneurysm Screening
• Blood Alcohol Misuse Counseling & Screening
• Cardiac Rehabilitation 
• Bone Density Screening
• Chemotherapy
• Cardiovascular Screening And Behavior Therapy
• Chiropractic Services
• Colorectal Cancer Screening
• CPAP Therapy
• Diabetes Screening
• HIV & STI Screenings
  
• Defibrillator Depression Therapy
  
• Durable Medical Equipment
• Glaucoma Test
• Emergency Department Services
• HPV Test 
• Eyeglasses After Cataract Surgery
• Home Health Services
• Hepatitis B Shots & Infection Screenings
• Kidney Dialysis Hepatitis C Screenings
• Laboratory Services
• Lung Cancer Screening
• Mental Health Coverage
• Second Surgical Opinion
• Vaccines
• Mammogram
• Organ Transplant
• Medical Nutrition Therapy
• Physical & Occupational Therapy
• Obesity Screening/ Counseling
• Prescription Drugs
• (Limited) Pelvic Exam
• PRosthetic & Orthotic Items
• Prostate Cancer Screening
• Pulmonary Rehabilitation
• Smoking & Tobacco Cessation Counseling
• Speech Language Pathology Services
• Wellness Visits
• X-Rays, MRI’s, CT Scans & EKG/ECG Screenings
• Transitional Care Management Services
• Urgent Care
  

As with other parts of Medicare and health insurance in general, Part B has exceptions. It does NOT cover the following:

1. Nonmedical long-term care
2. Dental care dentures
3. Vision care and eye exams for prescription glasses
4. Exams for hearing aids (and the hearing aids themselves)
5. Cosmetic surgery
6. Acupuncture
7. Prescription drug coverage (provided by Medicare Part D)
8. Skilled nursing facility services (covered by Medicare Part A)

Advantage Medicare Plans cover more services than Medicare A and B but the coinsurances, copays, other fees should be looked at closely. Also, the providers usually have to be in the network.

Long Term Care (LTC) Insurance covers different services for different policies. Be sure to read your policy and talk to your company to know the details and qualifications you or the client must meet to receive those benefits. 

Private Home Care Companies are usually very adept in working with LTC Insurance companies to provide information about the care needed as well as facilitating payment for services. Private Home Care Companies are NOT Home Healthcare Companies. Private Home Care companies will be discussed in a later chapter. These companies usually only take private payments and payments from Long Term Care Insurance Companies. 

Supplemental Insurance to Medicare (Medigap)- helps to cover costs not covered by Medicare A or Medicare B. However, there are specific items it does not cover. Private Home Care being one of them.

Independent living is simply any housing arrangement meant for older adults, usually 55 years old and over. Since this arrangement serves those who need little to no assistance, there is usually no medical or nursing care available. The situation usually entails them residing in a cottage or apartment on the grounds, owned by the company, and most of any assistance that is provided is 24/7 on-call person for emergencies, possibly 1-2 meals a day provided to them. All they have to do is go to the dining area or main building to pick up their meal. The “cottage” or “apartment” has a floor plan convenient for those who may need a wider door frame for walkers, wheelchairs, and handicapped devices installed in bathrooms, etc. Other amenities may include a common area to connect with peers, activities, recreational centers, libraries, clubhouses, arts and crafts, education classes or movie nights. Some situations also include housekeeping assistance, laundry services, beauty and barber salons and occasionally onsite spas. Other examples of independent senior living are:

• Low-income or subsidized senior housing

• Senior apartments or congregate care housing

• Retirement homes/ Retirement communities

• Continuing Care Retirement communities (CCRC’s) – This type of community has services onsite that range from independent to nursing home care.

The cost of such living situations varies depending on the amenities offered and size of living space. It can range monthly from $1000/month up to $10,000/month. In addition most communities ask for an initial charge up front of $500 to $1500 one time entry fee. 

Private Homes– Of course you know that this is the home you are buying, have bought, or are renting.  There are no services added except those you hire privately to come into your home.

Assisted Living Facilities are rooms or apartments under one roof and house those seniors that require assistance with their care. The extent of care can be from just having meals available to a highly functional senior to having personal care, incontinent care, and both usually include laundry services and housekeeping of the unit. The assisted living facilities vary also in cost based on amenities, ambiance of the community, and the services provided. Some even include transportation. The cost varies by state and location and can be as high as $4500/month.

One important consideration when you are applying to be admitted to an ALF; the senior is required to be able to ambulate (walk with a walker or cane, or wheel self) Look for the facility’s state survey (this should be in clear sight of the visitor) to learn of quality of the care provided. Ask about how many caregivers are available per occupant. Each state has its own regulations regarding this ratio. Ask about training that the staff receives and qualification of the staff. Oftentimes, it is difficult for the senior spouse or adult child of the senior needing care to provide all care needed and the ALF provides all of this 24/7 providing a huge relief to both the spouse and adult child. Visitation is usually open and unlimited unless there is a health concern for the entire community. Assisted Living Facilities also offer day programs for a fee. You can take advantage of this by calling and asking the ALF you have in mind of their arrangement for “respite” care or day programs.

Respite care is where the senior goes to the ALF for a set number of days to give the spouse or adult child a break. Oftentimes, this is done when the spouse or adult child caregiver needs to go out of town for a function or a vacation. Costs for this range from $100- $250/ day depending on the amount of care needed. If day programs are needed, ask about that cost when you call. Costs for ALF services are always paid for privately by the client and ALF’s usually also take payment from Long Term Care Insurance and work very well with them. The Veterans Administration may also be helpful in paying for care. The ALF usually is able to help you navigate the VA application for this help. If your veteran senior does have a primary care team at their local VA, this will be easier to navigate for both you and the VA.

Dementia or Memory Care can be provided in a facility specifically to meet the needs of clients who suffer from different stages of Dementia. Their needs can range from a secure unit or building, to having to be bathed, dressed, fed while being non-communicative. These facilities are operated similarly to the ALF’s. Some also offer respite and day programs. The cost of these facilities is usually a private pay arrangement however, some also accept Long Term Care Insurance arrangements that pay for care. The VA can also be helpful here for veterans and an application has to be submitted. The cost can range upwards of $5300/ month. Caregivers in these type situations should be trained in Dementia care extensively. Caregiver to client ratio should be lower with memory care facilities than a routine ALF.

A Personal Care Home is in essence a home environment (usually a private home that’s been converted to accommodate those seniors needing handicapped access) that also meet the regulations for personal care homes for the specific state. The staff that care for these clients are oftentimes not extensively trained in caregiving and the personal care homes are often not owned by a company but an individual. Personal Care Homes are ordinarily located in neighborhoods. Advantages to this type of care can be cost, which would be lower than a typical ALF; the number of clients who live in this facility are low, usually 4-8.

Typically there is a caregiver during the day and one at night. Caregivers will help with personal care, dressing, preparing meals, feeding, activities, laundry, housekeeping, and medication management. These clients are usually able to walk, use a walker or cane, or wheel their own wheelchair. The home can be a secured home keeping a “wandering” client safer but transportation to appointments, to run errands are not typically provided. The same applies regarding cost as does ALF’s or Memory Care facilities. Payment arrangements for personal care homes can also include acceptance of Medicaid depending on the state. 

You may be able to have your charge participate in an adult day program where they can socialize with others in similar situations. Usually they have activities at the facility such as arts & crafts, reading circles, playing physical and non-physical games (Bingo, cards, ball games etc.), music programs and light exercise programs. These programs are limited in occupancy and require you to apply for them.

The cost varies from free to sliding scale based on income, to $250. / day. They are offered by churches, senior centers, and dementia groups. This allows you to have some time to yourself to do the shopping, run some errands, volunteer elsewhere, work a part-time job or just rest and relax. Medicare Advantage plans may absorb some of the costs for Adult Day Programs but they are not required to do so. Go to your county social services or aging programs to see programs specific to your area. The Veterans Administration may be able to provide some financial assistance to help pay for services. See my resource page for website details.

These facilities are exactly what they imply; a client can go from a living situation “cottage” or apartment where they are independent to an assisted-living room in a facility with increasing levels of care provided to nursing homes or skilled care facilities requiring nursing procedures, treatments and rehabilitation. This arrangement is convenient for the client as they would stay in relationship with the same company and often stay on the same site just in different buildings to maintain their care. The cost is covered as it is in ALF’s Memory Care Facilities, but if a client needs the highest level of care in the nursing home building the costs would be higher.

If a client has been in the hospital and goes directly into the rehabilitation wing of the nursing home facility, then Medicare, Medicaid or private insurances could pay a portion of the cost. This would be effective as long as the client is progressing. Once the client plateaus or levels off, then private payment, Long Term Care Insurance, VA assisted, or Medicaid could one pay for care. While in any of these continuum of care facilities one can expect to pay anywhere from $20,000 and upwards of $500,000 depending on whether the client purchases their unit. The average initial payment is $329,000. but can top $1 million at some communities. After the resident or client moves in, they pay monthly maintenance or service fees that typically run $2000. to $4000. Other continuing care communities operate on a rental model with no up-front fee.

Skilled Nursing Facilities house long term clients as well as short term clients. These clients need more specialized and complicated care, however, skilled nursing facilities also take clients directly from the hospital or acute care setting after discharge in order to offer rehabilitation to enable the client to return home after they are more able to provide their own care. Physicians act as Medical Directors and are in essence the clients’ Primary Care Physician at this point.

Registered Nurses supervise the care by all other disciplines such as Licensed Practical Nurses, Certified Nursing Assistants. Medicare/ Medicaid will typically pay the cost of rehabilitation up until the client stops progressing. If the client then stays in the skilled care setting they will be expected to pay out of pocket for the “room & board” at a daily rate resulting in an average charge of between $12,000-$13,000/month depending on semi-private or private situation. Long Term Care Insurance will assist with payments if you’ve purchased a policy of this type and VA can help assist with the cost, however, usually this type of cost is paid for by the client privately.

Medicare does not pay for the cost after rehabilitation has been suspended or stopped. Medicaid can help pay for the charges if the client qualifies for Medicaid. Medical Insurance does not pay this charge after rehabilitation stops. 

There are situations where upon discharge from the hospital the senior doesn’t qualify or need skilled nursing home rehabilitation. If these clients do not have arrangements worked out for other care choices whether it be in-home, independent, ALF, Personal Care Home, Continuum of Care Facility, Dementia or Memory Care, they could be allowed to stay in the hospital (dependent on bed availability) for a daily charge for “swing bed” until arrangements are worked out for their care in any of these scenarios. The cost for this status is charged on a daily basis at an average of $300/day. In some cases if the senior is awaiting availability of a room in a skilled nursing facility and a skilled level of care is being delivered to the senior while they stay in a “swing bed” in the hospital Medicare or Medicaid probably will pay for the charges. Most often if the senior is awaiting for arrangements to be finalized in the home setting they will be expected to pay privately for the daily rate.

Hopefully at this point you have the valuable information you need to know how to choose what type of Medicare programs and supplemental insurance you may need to insure that you have your healthcare needs met. The Care Options section is also meant to inform you of what type of care is available to seniors and the costs involved.

There are those that close their eyes to the facts and choose to think that there are departments, agencies, or groups out there that would be stepping up to help them when they get that bill in the mail for the 20% that Medicare didn’t cover (instead of choosing supplemental insurance) , when they are faced with paying for private home care at $30/hr on average because Medicare, nor other supplemental insurance will pay for custodial care (the only insurance that does is Long Term Care Insurance), or when the adult children of the senior needing custodial care are unable to be “hands-on” to care for their parent when needed (as their other parent is unable to provide the ongoing 24/7 oversight care that their senior parent in need requires). For you who are between the ages of 35- 80; seniors are living longer and are healthier than ever. Even if you are 35 your parent unfortunately could suffer some health disability causing them to have to stop working earlier than 62 (when a person can begin taking Social Security).

Dementia can occur in people as young as 50-55 and it’s a 20 year journey before the disease causes decline to the point of death. This puts a burden on the parent, senior, or spouse that is left to wrestle with the costs, the responsibility of doctor’s appointments, and care needed at home (or elsewhere). At the age of 35-40 would you as an adult child be able to supplement some of your income to help pay for custodial care (in the event your other parent could not pay for it)? Keep in mind, you may also be stretched thinner due to that child graduating from high school and needing to attend college (another expense for you). This age group is often referred to as the “sandwich generation” because they are sandwiched between their responsibility to their children and their aging parents. If your parents plan ahead this scenario of everyone being financially stretched will most likely be avoided. What is it Ben Franklin said? “ An ounce of prevention is worth a pound of cure.”? You have the information now. Sit down with your parents (no matter the age) or your spouse and discuss calmly and contemplatively the needs that are to come and the possible solutions to avoid hardship for everyone.