What does Medicare have to do with my care home?
Those of us around the assisted living industry know that Medicare generally does not cover the cost of long-term care (room and ADL services) in an assisted living home. Why, then should assisted living owners and operators care about what Medicare coverage plans their residents have? There are probably a lot of reasons why a very basic understanding of Medicare is important to the assisted living home owner or operator, but we’ll address three of them in this article.
1. Special Enrollment Periods (SEPs)
A resident can join or change Medicare plans upon move-in to an institutional setting, such as a licensed assisted living facility, as part of a “Special Enrollment Period” (SEP), as a result of their changed circumstances. (See: Medicare Special Enrollment Periods) Upon moving into an assisted living facility, the individual typically loses access to their Primary Care Provider, who does not make house calls, and they often must chose a different mobile PCP. The move into an assisted living setting can also follow some type of health crisis that results in a change to their medication regimen, and the individual may benefit from a different provider for Part D coverage.
By having a trusted, licensed Medicare plan-contracted insurance agent on-call to assist the new resident and their family with analyzing their current coverage and determining if there might be a better plan available to serve their needs in the new setting, the facility owner is able to provide a concierge-like experience to the onboarding process. Families are generally overwhelmed with the changes they are experiencing and don’t understand all the nuances of Medicare coverage for the doctor visits and prescription medications that the resident will be receiving in the assisted living setting. Since the out-of-pocket cost of care will usually be significant, they will generally be appreciative if the facility owner is able to connect them to a professional that may be able to find them some cost savings or enhanced benefits for their loved one during their assisted living stay. Affiliating with an insurance agent who is knowledgeable in this field can help the assisted living owner stand-out from competitors, who do not offer this level of attention to their clients.
2. Becoming Eligible for both Medicare and Medicaid
If a resident becomes eligible for Medicaid during the course of their residency, they are able to join, switch, or drop their Medicare Advantage Plan or Medicare prescription drug coverage during certain (broad) time periods:
January–March
April–June
July–September“If you make a change, it will take effect on the first day of the following month. You’ll have to wait for the next period to make another change. You can’t use this Special Enrollment Period from October–December. However, all people with Medicare can make changes to their coverage from October 15–December 7, and the changes will take effect on January 1.”[1]
In Arizona, there are certain dual-advantage plans offered by health plans to persons eligible for both Medicaid and Medicare. The state organization that processes Medicaid applications, AHCCCS, generally will not thoroughly explain these plan options to persons upon Medicaid enrollment. For example, some plans may provide the member with nutritional benefits, such as a “healthy-eating” grocery or nutritional supplement allowance that can be used to purchase produce, protein-meal-supplements, or over-the-counter-vitamins that Part D does not cover. By coordinating delivery of these supplies with the families, the facility can reduce the resident’s out-of-pocket expenses, and possibly also defray the facility’s food costs for grocery items that would otherwise be purchased for that resident.
Similarly, many of these plans cover transportation to and from medical specialists’ appointments. Residential assisted living homes are generally at a disadvantage over large facilities that have their vans available to transport residents to healthcare appointments and recreational activities. If all the resident needs, however, is a trip to the cardiologist twice a year and dermatologist annually, and the home can assure the family that it will coordinate the transportation pursuant to the resident’s Medicare advantage or dual plan coverage, perhaps that could influence the decision to place that resident in a home-like setting rather than the large facility.
Thus, understanding some high-level basics of the various Medicare and Medicaid programs may help defray costs for not only the resident’s representatives, but also the facility itself.
3. Scammers
The term may be harsh, but statistics show that:
Older people are swindled out of more than $3 billion each year.
More than 3.5 million older adults are victims of financial exploitation each year.
Seniors targeted by fraudsters suffer an average loss of $34,200.[1]
We are aware that cold-callers are targeting people to talk to them about their Medicare coverage. This is a violation of federal law. CMS has very specific rules regarding Medicare advisor communications and marketing and specifically prohibits such unsolicited phone calls, text messages, and door-knocking. See 42 CFR § 422.2264 (Beneficiary contact). As more and more people move into the assisted living setting with their own cell phones, Alexa’s, Echoes, and internet access (email communications are also addressed in that Federal Rule), there is an increased possibility that those residents may fall prey to someone who is violating the rule. The caller could collect information that could put the resident in a less-desirable Medicare-plan for their medical needs, while scoring the cold-caller or door-knocker a nice sales commission. Although these types of unsolicited communications might not directly take money from the elderly individual, they are unlawful. If an assisted living operator suspects that a resident may be being unduly influenced to change their Medicare plan coverage, the facility owner is usually in a front-line position to communicate with the resident’s family or contact CMS or APS about these callers who are unlawfully preying on the elderly just to pad their own wallets. We suspect these calls will only increase as the Open Enrollment Period of October 15 – December 7 approaches.
In conclusion, Medicare insurance professionals serve an important role in the assisted living industry. By way of full disclosure, I’m proud to be married to one. I also know his angst when he discovers that someone changed their plan because they saw a commercial on daytime TV with a former celebrity hyping a program that was not actually suited for their specific medical needs. Medicare and Medicaid rules and insurance plans are complicated. They vary from state to state and even county to county.
As an assisted living owner, you don’t need to know the rules, nor the plan benefits. Expanding your network to know someone who does work in that area so that you can refer the family to them (or have the family authorize the agent to contact them per CMS rules), and having a high-level awareness that a new resident is not “stuck” with their current plan if it doesn’t serve them in the new setting, may give your home an advantage over your competitors, and result in more and better resident placements over time.
Look for more weekly blog posts on topics of interest to Assisted Living and Behavioral Health operators. The information herein is intended to be educational and an introduction to the subject matter presented. It is NOT specific legal advice to be relied upon for specific individual circumstances. Contact your own legal professional or reach out to our firm if you would like specific advice on this topic. We welcome topic suggestions! Write to info@pinkowskilaw.com if you are curious to learn more about a certain topic impacting assisted living or other group housing concerns.
[1] Medicare & Medicaid Eligibility
[2] Consumer Affairs reports on elderly financial scams