Another Medicare ruling that is particularly loathsome for family caregivers is the refusal to pay for the cost of a fully electric bed, even if the caregiver’s back has already been damaged by bending and lifting and her or his ongoing health is at risk.
Medicaid
Unlike Medicare, Medicaid pays for many long-term care services for people meeting its strict financial guidelines—though the most frequently funded services are those in nursing homes and other long-term care facilities. Whereas Medicare is administered by the federal government, Medicaid is not. Many of the program’s services vary from state to state, but all states must pay the cost of care in a nursing home or other institutional setting for those who qualify. Legislation has been proposed to actually give Medicaid beneficiaries control over an individual budget for personal care and related services—often referred to as the “Cash and Counseling” model. Generally, however, Medicaid funding goes directly to service providers and beneficiaries do not have much of a say in how it is spent.
In the initial Cash and Counseling demonstration projects that were conducted in three states (Florida, Arkansas, and New Jersey), money was provided directly to Medicaid recipients to determine (within reason) how they wanted to spend it. These demonstrations have proven very successful. In some cases, people decided to pay a family member to provide their care services. This program is now being expanded, and twelve additional states are in the process of implementing Cash and Counseling programs. A related concept is the “Money Follows the Person” program, which is also being expanded. It provides funding for individuals to move from nursing homes to community-based settings, and is something for family caregivers to watch. Aging and Disability Resource Centers (ADRC) are being developed on the state level to create a single, coordinated system of information and access for all persons seeking long-term support. The goal is to minimize confusion, enhance individual choice, and support informed decision making. Currently, forty-three states have received grants to create an ADRC. The idea is to provide “one-stop shopping,” so regardless of which state you live in you can call a central number to find the answers to your questions. The idea is a great one and it is exciting to see this beginning. It will take a while for many programs to become fully operational before we know if the programs will truly have resources and programs specifically for family caregivers or only for their care recipients. Making sure they do would be a good activity for someone who wants to get involved and help make life better for family caregivers in their state. Nursing home care costs average $57,000 a year, and can be twice as much in major metropolitan areas or in hard to reach places. In Alaska for instance the average cost is $167,000 annually. Most of us can’t come up with that kind of money. Since Medicaid was specifically designed for low income individuals and families who do not have insurance or resources to pay for their healthcare, middle-income people have truly been caught in the middle with Medicare not providing long-term care services at all and Medicaid only providing it for a strictly defined population.
To make the situation more equitable for the middle class, Congress established rules for long-term care that allow individuals to “spend down,” which is a euphemistic way of saying deplete, their assets and thereby qualify for assistance. It used to be that when a two-person household was involved, for example a husband and wife living together, this “spend down” practice left the well spouse (often referred to as the community spouse) in poverty without enough income or assets to cover his or her own basic needs. According to changes to the 2007 Medicaid guidelines, spawned by the efforts of advocates for the elderly, community spouses are allowed to maintain between $1,650 and $2,541 a month of income, and between $20,328 and $101,640 in assets, as well as their house, car, and other personal effects and still be eligible for payment of nursing home fees. Because Medicaid is administered at the state level, actual numbers vary across the country.
