January 3, 2013

Your Advocacy Connection – We Solve Long Term Care Problems

By Julie Arndt
GolderCare Solutions

I’m a Care Advocate at GolderCare Solutions. At GolderCare, we solve long term care problems. As we approach the arrival of 2013, our office has received many calls reflecting the uncertainty of our times. Healthcare and tax reform seem to be the cause of some of this unrest. As a general rule, people don’t like change. It fosters uncertainty and decreased confidence in what we know. However, it is particularly in times like this that it is ever so important that we arm ourselves with as much knowledge as possible to ensure we are maximizing our options, both in terms of healthcare and paying for care.

One issue that seems to be confusing to many of our senior clients is the difference between “observation” and “acute care’ status in the hospital. For Medicare purposes, an observation stay is considered outpatient care and acute care is considered inpatient care. Typically our clients or their families contact our office when there has been a medical event prompting a hospitalization, and all too often, they give the report back to us “they decided to keep her,” What does this mean? Is she being admitted into the hospital or are they keeping her for observation? The answer will have a very significant impact on several things.

For instance, let’s say Mrs. X requires post acute rehabilitation in a nursing facility. In order for Medicare to pay towards the nursing home, she must meet certain criteria for the nursing home stay, with first criteria being the need to spend three midnights in acute care (non-observation status) within thirty days of the admission to skilled care. There are other factors to be considered, but I’m referring only to the “three day inpatient (acute care) stay” criteria. Years ago, Medicare would allow only a 23-hour period of observation. After 23 hours, a decision needed to be made by your physician whether to admit you as an inpatient versus discharge. This is not the case today. An observation stay can continue for several days without you even knowing it. It’s a surprise to some who are admitted to a skilled facility under the assumption Medicare will be covering it, only to find they were never formally admitted to the hospital, but spent several days in observation.

We recommend anyone admitted to the hospital clarify with the case manager or social worker on their unit exactly what their admission status is. It’s probably a good idea to get this in writing. You won’t know unless you ask. Even if skilled nursing care is not required post acute, this will still impact your cost. Inpatients (acute care) pay a large deductible, after which Medicare Part A covers the hospital and inpatient related service charges. Observation stays are considered an outpatient service, thus co-payments for each hospital service will be billed under Medicare Part B.

One should also be familiar with their Medicare benefits. There are many changes to the Medicare Advantage Plans coming in 2013. Don’t make assumptions that coverage will be the same as last year.

One example of this is the AARP United Healthcare Advantage Plan, specifically AARP MedicareComplete Plan 2 (HMO), one of the more popular plans in our area due to the zero premiums. The big change for 2013 for this plan is that the Point-of-Service (using any doctor, specialist or hospital) will no longer be available. The plan will only cover providers and facilities in their network. Previous ‘in-network’ and ‘out-of-network’ benefit levels are now combined to create just this one benefit level. Consumers should be sure to review the “Changes” section of their 2013 Plan Materials Book for details regarding additional changes. If you need a list of your providers, you should contact your insurance agent or visit on-line. Regardless of what plan you have, changes have been made in response to the 2010 Affordable Care Act.

There are many changes going on in our world, government and healthcare delivery systems. It is critical that consumers are informed. At GolderCare, we believe you have the right to be informed so you can maximize your options for healthcare and determine the best way to pay for your care.

Julie Arndt is a licensed social worker working in the field of geriatrics for over twenty five years with expertise in medical case management and community based services.