Olmstead/Community First

Mass Home Care presented the
following list of specifi c program goals as ‘next
steps’ in the Olmstead/Community First movement:
1. Implement Long-term Care
Options Counseling statewide.
2. Implement the Community First (CF)
1115 waiver program, enhanced services,
with enhanced income and asset rules.
3. Support expansion of respite care capacity for caregivers.
4. Improve funding for case management, medication
management, behavioral health, and caregiver supports
5. Submit a Home and Community Based
Services (HCBS) State Plan Amendment (SPA)
to uncouple HCBS from nursing home eligibility.
6. Increase funding and community-based
services for people who are not low-income
or otherwise not eligible for MassHealth.
7. Remove barriers to community-based care,
make eligibility rules uniform regardless of age.
8. Implement PCA Improvement workgroup
recommendations, including allowing
cueing and supervision to be a need for
care, and creation of the PCA directory, etc.
9. Allow spouses to become paid caregivers
in programs like PCA and Adult Family Care.
10. Increase supply of supportive housing sites,
and 24/7 “housing with services” packages,
including small group homes, using funding from
Community Housing bond and other sources.
11. Implement and fund the ADRC model statewide.
12. Implement mandatory training in cultural competency
on LGBT issues, and a statewide needs assessment of
LGBT individuals with disabilities and the elderly.
13. Increase funding for the protective
services programs, and education on reporting
responsibilities under the abuse and neglect law.
14. Create a medication assistance program for
elders and individuals with disabilities in their homes
by amending the nurse practices act requirements.
“The key to any plan is its implementation,” said
Paul J. Lanzikos, President of Mass Home Care. “We

Pace Program All Inclusive Care

The Program of All-Inclusive Care for the Elderly (PACE) is a capitated benefit authorized by the Balanced Budget Act of 1997 (BBA) that features a comprehensive service delivery system and integrated Medicare and Medicaid financing. The program is modeled on the system of acute and long term care services developed by On Lok Senior Health Services in San Francisco, California. The model was tested through CMS (then HCFA) demonstration projects that began in the mid-1980s. The PACE model was developed to address the needs of long-term care clients, providers, and payers. For most participants, the comprehensive service package permits them to continue living at home while receiving services rather than be institutionalized. Capitated financing allows providers to deliver all services participants need rather than be limited to those reimbursable under the Medicare and Medicaid fee-for-service systems.

The BBA established the PACE model of care as a permanent entity within the Medicare program and enables States to provide PACE services to Medicaid beneficiaries as a State option. The State plan must include PACE as an optional Medicaid benefit before the State and the Secretary of the Department of Health and Human Services (DHHS) can enter into program agreements with PACE providers.

Participants must be at least 55 years old, live in the PACE service area, and be certified as eligible for nursing home care by the appropriate State agency. The PACE program becomes the sole source of services for Medicare and Medicaid eligible enrollees.

An interdisciplinary team, consisting of professional and paraprofessional staff, assesses participants' needs, develops care plans, and delivers all services (including acute care services and when necessary, nursing facility services) which are integrated for a seamless provision of total care. PACE programs provide social and medical services primarily in an adult day health center, supplemented by in-home and referral services in accordance with the participant's needs. The PACE service package must include all Medicare and Medicaid covered services, and other services determined necessary by the interdisciplinary team for the care of the PACE participant.

PACE providers receive monthly Medicare and Medicaid capitation payments for each eligible enrollee. Medicare eligible participants who are not eligible for Medicaid pay monthly premiums equal to the Medicaid capitation amount, but no deductibles, coinsurance, or other type of Medicare or Medicaid cost-sharing applies. PACE providers assume full financial risk for participants' care without limits on amount, duration, or scope of services.

Long Term Health Care Insurance

Young Workers Must Face Realities of Long-Term Care
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By FRAN HAWTHORNE
Published: October 22, 2008



Michael Hogue

Retirement
A Special Section
Strategies for retirement in a troubled economy.

Go to the special section » MOST of the nation’s 78 million baby boomers are watching their parents grow old. While investigating caretaking options for their parents, they should also be thinking about their own old age and planning how they will pay for nursing homes or home health aides for themselves, experts say. With life expectancy steadily rising, the odds are that they will eventually need some help with basic functions, like dressing or walking, maybe for decades.

But many boomers are ignoring this prospect.

“You’ve got your 401(k) to fund, you’ve got rising health care premiums, gasoline is up, groceries are up, said Randall K. Abbott, a senior consultant in the Boston office of the benefits consulting firm Watson Wyatt. “Folks tend to look at their wallets and decide it’s something they can’t think about right now.” Besides, he said, “people just don’t believe it’s going to happen to them.”

If they were to pay attention, they would learn that Medicare does not cover these ongoing, nonmedical services. Medicaid does, but it has tightened its rules, making it harder for middle-income people to qualify. That leaves essentially two choices: pay cash or buy long-term care insurance.

Long-term care insurance covers services for people who are unable to perform two or more activities of daily living. It can pay for a nursing home, assisted living facility, home health aide, adult day care and family respite (someone to fill in for a family member who is caring for the insured person).

And it is not just for the elderly; young people who are paralyzed by car accidents, for instance, often need home care.

About seven million of these policies had been sold as of Dec. 31, 2007, with sales increasing slightly over the past year, according to Limra International, a trade group in Windsor, Conn. The choices among these plans can be mind-boggling. Here are some critical issues to consider:

DO I REALLY NEED THIS COVERAGE?

Buying insurance is always a bet on probability. For long-term care, there are four basic questions to ask:

If I don’t buy insurance, how much money can I afford to spend on this care from my own assets and income? AARP reported that the average cost of a nursing home in the United States last year was about $214 a day; a home health aide was around $19 an hour.

Do I have alternatives? Are there friends or relatives who would take care of me — without charge?

What is the likelihood that I will need this care? (This is, admittedly, an uncomfortable question.) Does my family have a history of debilitating chronic illness, like Alzheimer’s disease? Or, on the other hand, do I have a heart problem that makes it unlikely that I will live long enough to use the benefit?

Can I afford the annual premiums, which can top $2,000? If someone’s assets or income is less than $40,000, “most likely you would be better off relying on Medicaid,” said Malcolm Cheung, vice president of long-term care product and risk management at the Prudential Insurance Company.

WHEN SHOULD I BUY IT?

Experts suggest that people buy policies while in their 40s to mid-50s, mainly because premiums rise with age, roughly doubling every 10 years. For a standard policy at New York Life Insurance Company, the annual rate is $1,041 at age 50, $1,941 at age 60 and $3,984 at age 70.

If buying at age 40 is good, why not start at 30? “Your first savings should be to take care of income replacement for retirement,” said Lawrence Singer, a senior vice president at the Segal Company, a benefits consulting firm in New York City. Another reason: “The likelihood of having a claim is really remote in the 30s, 40s and 50s,” he said.

But an applicant can also be too old. The cutoff at some major insurers is age 79; New York Life will sign new policies for those up to age 85, but with limited benefits.

WHERE CAN I GET IT?

“Look for it at the work site first,” Mr. Singer said. More than one-third of companies now offer long-term care insurance as a benefit, doubling the number from 10 years ago, according to Hewitt Associates, a benefits consulting firm in Lincolnshire, Ill.

Employer-based plans have multiple advantages, experts say. Mr. Abbott of Watson Wyatt noted that the group rates are typically 5 to 15 percent lower than retail and “they often have features and benefits that are more difficult to find in individual plans.” Moreover, the employer will have vetted the insurance carrier. One more advantage: policy owners will not need medical screening.