Medicare Information for Caregivers
If one of your friends, relatives, or loved ones needs help managing health conditions, treatments, and paying for health expenses with Medicare, you may find yourself in the role of caregiver.
As a caregiver, you may be asked to make important recommendations and decisions in all of these areas, in addition to helping with everyday needs. It is important to have a strong understanding of how Medicare works and the various benefits covered by different plans, so that you’ll be in a better position to care for your loved one’s health needs.
Understanding your loved one’s Medicare coverage
When you find out that a relative or friend needs your help due to a medical condition, first begin by talking to the person and people who know that person well. Find out what the beneficiary’s care and drug needs are, and who has permission to act on her or his behalf.
Next, you need to identify the person’s current health insurance coverage. If the person is covered by Medicare, find out whether their coverage is through Original Medicare (Part A for hospital coverage and Part B for medical coverage), a Medicare Advantage plan, or a Medicare Supplemental plan. You’ll also need to know whether the person has any prescription drug coverage. You can find this information on the beneficiary’s Medicare card. If the person is enrolled in a private Medicare plan, such as a Medicare Advantage plan or Medicare prescription drug plan, he or she will have a separate plan member card.
If the beneficiary’s Medicare card is not available, you can either call Medicare together, or the beneficiary can fill out a form authorizing Medicare to release information to you. To get an authorization form, call Medicare at 1-800-MEDICARE (1-800-633-4227) (TTY users 1-877-486-2048). If the beneficiary isn’t currently enrolled in Medicare, find out when they will be eligible to enroll.
As you, the caregiver, and the beneficiary work together to manage his or her health care using Medicare benefits, it is helpful to have the following information about the beneficiary:
- Social Security number
- Medicare number and type of Medicare coverage
- Other insurance plans and policy numbers, including long-term care insurance
- Contact information for health-care professionals, including doctors, specialists, nurses, and pharmacists
- Current list of prescription and over-the-counter drugs and herbal remedies, along with the dosages
- Current health conditions, treatments, and symptoms
- History of any past health problems
- Any allergies or food restrictions
- Emergency contacts, close friends, neighbors, clergy, housing manager
- Where to find financial and legal information, including the person’s living will and medical power of attorney
If you have a Medicare question or concern, a good resource is the State Health Insurance Assistance Program, or SHIP. SHIP gives free health insurance counseling and guidance to people with Medicare and to caregivers like you who have authorization to help someone with Medicare questions. (In some states, SHIP is known as SHIBA or SHINE.)
Paying for Medicare and health-care costs
As a caregiver, you should find out if the beneficiary has health coverage besides Medicare, such as a health plan with a former employer, Medicaid, or other insurance that can help pay for health-care needs.
Depending on the beneficiary’s income level and resources, there may be additional programs available to help pay for health-care costs. Medicare Savings Programs (MSPs) can help pay for Medicare copayments, premiums, and deductibles for low-income individuals. For those who qualify, the Medicare Extra Help program offers a low-income subsidy for prescription drugs. Another option may be the state-run Medicaid programs, which help with medical and long-term care expenses for low-income individuals and families.
Illness and hospitalization
Caring for an individual with a chronic health condition can raise additional questions and concerns, both for the beneficiary and the caregiver. As a caregiver, it is important to talk openly with the person about the illness and treatment, including what the doctor said during visits. Going over the facts may relieve some concerns and give a more realistic picture of the situation. Patients struggling with ongoing pain can feel anxious or depressed on top of their health issues, so being emotionally supportive can be an important part of managing their care.
Make sure to explore what kind of coverage Medicare Part A offers in instances of hospitalization. When a beneficiary’s doctor recommends surgery or a major medical test, you should encourage the beneficiary to get second and even third opinions. Getting a third opinion is especially important when the first and second opinions are different. Seeing a second or third doctor can provide information that helps patients decide on the best course of action for their health.
Beneficiaries with Original Medicare don’t need a referral from a primary care doctor before seeing a specialist or getting a second opinion. For those enrolled in a Medicare Advantage plan, keep in mind that some plans (such as HMOs) may require you to get a referral from your primary care doctor before you can get a second or third opinion.
If the person you’re caring for has Original Medicare, you should always ask if a doctor or supplier accepts “assignment” before proceeding with care. Assignment is an agreement between Medicare doctors, health-care providers, and suppliers to accept the Medicare-approved amount as payment in full. If a doctor or supplier does accept assignment, the beneficiary will be responsible for their cost-sharing such as the deductible, co-payment and/or co-insurance.
If a beneficiary needs to be hospitalized, Medicare covers inpatient hospital care when all of the following are true:
- A doctor says that inpatient hospital care is medically necessary to treat the Medicare beneficiary’s injury or illness.
- The Medicare beneficiary needs the kind of care that can be given only in a hospital.
- The hospital has an agreement with Medicare.
- The Utilization Review Committee of the hospital approves the stay while the Medicare beneficiary is in the hospital.
If a beneficiary is hospitalized, Medicare helps pay for certain types of services:
- Care — general nursing
- Room — semi-private room
- Hospital services — meals, most services and supplies
If a beneficiary is hospitalized, Medicare does NOT pay for the following services:
- Care — private-duty nursing
- Room — private room (unless medically necessary)
- Hospital services — television and telephone
- Personal care items — razors and toothbrushes
For more information about Medicare Part A, visit www.medicare.gov and view or print a copy of “Your Medicare Benefits” and “Medicare & You.”
Medicare prescription drug coverage
Medicare prescription drug plans offer prescription drug coverage for beneficiaries with Medicare. To get Medicare prescription drug coverage, a beneficiary must join a prescription drug plan run by an insurance company approved by Medicare. Each prescription drug plan varies in costs and drugs covered.
There are two ways to get Medicare prescription drug coverage: a Medicare prescription drug plan (PDP) or a Medicare Advantage Prescription Drug (MAPD) plan.
1) Medicare prescription drug plan: To join a Medicare prescription drug plan, a beneficiary must be enrolled in Medicare Part A and/or Part B. The beneficiary must also live in the service area of the Medicare prescription drug plan.
Medicare prescription drug plans add drug coverage to Original Medicare, Part A and/or Part B, some Medicare Cost plans, some Medicare Private Fee-for-Service (PFFS) plans, and Medicare Medical Savings Account (MSA) plans.
2) Medicare Advantage Prescription Drug plan: To join a Medicare Advantage plan (like an HMO or PPO), a person must have Original Medicare, Part A and Part B.
Medicare Advantage (MA) plans, such as Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), or another Medicare health plan may include prescription drug coverage. In this case, beneficiaries get all of their Medicare coverage through these Medicare Advantage Prescription Drug (MAPD) plans.
Other types of prescription coverage
Some beneficiaries may also have prescription coverage in addition to Medicare, such as through employer-sponsored coverage or veterans benefits. In these cases, Medicare uses “coordination of benefits” guidelines to determine which insurance pays first. If you’re caring for someone who has more than one type of coverage, you can call the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY 1-855-797-2627) to find out how Medicare works with your other coverage.
Some types of drug coverage your loved one may have, in addition to Medicare, could include:
- Employer or Union-Sponsored Drug Coverage: Beneficiaries may also get drug coverage if they are enrolled in an employer or union-sponsored plan. If a beneficiary has prescription drug coverage from a former or current employer or union, you should contact the plan’s benefits administrator before making any changes to the drug coverage. Joining a Medicare prescription drug plan could change how the beneficiary’s employer or union coverage works, both for the beneficiary and any dependents covered by the plan.
- Other prescription drug coverage: A beneficiary can also have prescription drug coverage from TRICARE, the Department of Veterans Affairs (VA), or the Federal Employee Health Benefits Program (FEHBP). Again, if this is the case, you should contact the plan’s benefits administrator or insurer before making any changes. In most cases, it will be to the beneficiary’s advantage to keep the current coverage. However, in some cases, adding Medicare prescription drug coverage can provide extra coverage and savings, especially if the beneficiary qualifies for Extra Help.
What Medicare prescription drug plans cover
Each Medicare prescription drug plan, whether it is a stand-alone plan or a Medicare Advantage Prescription Drug plan, has a list of prescription drugs that it covers. This list is called a formulary, or drug list. Plans may cover both generic and brand-name prescription drugs. Most prescription drugs used by Medicare beneficiaries will be on a plan’s drug list. To find out which drugs a plan covers, contact the plan or visit the plan’s website.
Medicare drug plans may have rules about prior authorization, quantity limits, and step therapy:
- Prior authorization means that the beneficiary and/or the doctor must contact the plan before certain prescriptions can be filled. The doctor may need to show that the drug is medically necessary for it to be covered.
- Quantity limits are limits on how many pills or doses a beneficiary can get at a time.
- Step therapy is a type of prior authorization in which a beneficiary must try one or more similar, lower-cost drugs before the plan will cover the drug the doctor prescribed.
If the doctor believes that one of these coverage rules should be waived, the person can ask for an exception. (If someone receives an exception, it means that a drug coverage rule does not apply in a particular case.)
How to choose a prescription drug plan
Having a variety of prescription drug plans to choose from gives Medicare beneficiaries the freedom to pick a plan that meets their unique needs. To help the beneficiary choose a plan that provides the right coverage at the best price possible, you as a caregiver can:
- Contact the Medicare plan directly
- Visit www.medicare.gov to view or print copies of “Your Guide to Medicare Prescription Drug Coverage.”
- Call 1-800-Medicare (1-800-633-4227) (TTY users 1-800-325-0778).
- Call the State Health Insurance Assistance Program (SHIP) in your state for personalized help.
- Contact a licensed insurance agency, such as eHealth Insurance Services, Inc .
You can also find information in the “Medicare & You” handbook, which is mailed out to Medicare enrollees during the fall. It contains detailed information about Medicare prescription drug plans, including which plans are available in your area.
Continuing care options
A serious illness or injury can create a need for ongoing care. With the right kind of support, some beneficiaries can continue to lead independent, productive lives at home. Others may need full-time care outside the home. For those who cannot recover, end-of-life care may be the answer. Medicare can cover costs for some continuing care needs described below.
Home health care
Home health care is short-term skilled care at home, after hospitalization, or for the treatment of an illness or injury. Home health agencies provide home care services, including skilled nursing care, physical therapy, occupational therapy, speech therapy, medical social work, and care by home health aides.
Home health services may also include durable medical equipment, such as wheelchairs, hospital beds, oxygen, walkers, and medical supplies for use at home.
If a beneficiary has Medicare, he or she can use the home health benefit if all of the following conditions are met:
- The doctor determines that the beneficiary needs medical care at home, and makes a plan for this care.
- It is medically necessary for the beneficiary to receive one or more of the following services: intermittent skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy.
- The home health agency selected must be approved by Medicare (Medicare-certified).
- The beneficiary must be homebound or normally unable to leave home unassisted. To be homebound means that leaving home takes considerable effort.
Beneficiaries may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to attend religious services. A beneficiary can still get home health care if he or she attends adult day care.
To find out if a beneficiary is eligible for Medicare’s home health-care services, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227); TTY users can call 1-977-486-2018, 24 hours per day, 7 days a week. If the doctor decides the beneficiary needs home health care, you as a caregiver can choose an agency from the participating Medicare-certified home health agencies that serve the area. To find an agency, ask the doctor or hospital discharge planner or use a senior community referral service or agency.
Home health agencies are certified to make sure they meet certain federal health and safety requirements. The choice of a home health agency should be honored by the patient’s doctor, hospital discharge planner, or other referring agency as long as it is a Medicare-certified agency.
Here are questions you should ask as a caregiver when considering a home health agency:
- Is the agency Medicare-approved (Medicare-certified)?
- How long has the agency served the community?
- Does this agency provide the services my relative or friend needs?
- How are emergencies handled?
- Is the staff on duty around the clock?
- How much do services and supplies cost?
- Will agency staff be in regular contact with the doctor?
You can use Medicare’s “Home Health Compare” tool to compare home health agencies in your area.
There are times when a beneficiary’s needs extend beyond the intermittent skilled care provided through Medicare. Community-based services across the country support independent living and are designed to promote the health, well-being, and independence of older adults. These services can also supplement the supportive activities of family caregivers.
Often, community-based senior citizens’ services offer companionship visits, help around the house, meal programs, caregiver respite, adult day care services, transportation, and more. These support services may be funded by state and county programs or offered by church or volunteer groups.
Nursing homes and housing options
Serious and chronic illness may create a need for full-time care outside the home. It is a decision the caregiver and the beneficiary should discuss with the doctor as well as other family members.
There are several categories of care available in most communities, ranging from daytime activities to full-time care. These include independent living facilities, assisted living facilities, continuing care retirement communities (CCRCs), adult day care, custodial care, skilled nursing facilities, and nursing homes. A description of each of these types of care follows.
Independent Living Facilities: These are settings designed for independent living while offering meals, social and recreational activities, and other support.
Assisted Living Facilities: These are residential homes offering a range of services that usually include limited assistance and supervision with daily living tasks, which can include cooking and medication management.
Continuing Care Retirement Communities (CCRC): A CCRC is a housing community that provides different levels of care based on residents’ needs.
Adult Day Care: Adult day care includes daily, structured activities and rehabilitation services for the elderly who need a protective environment. Care is provided during the day, and the individual returns home for the evening.
Custodial Care: Custodial care provides assistance with daily activities such as bathing, eating, and dressing.
Skilled Nursing Facilities: These are facilities with 24-hour supervision and medical and rehabilitative services for patients requiring a high level of care. Medicare covers skilled nursing care after a three-day qualifying hospital stay. Skilled care is health care given when the beneficiary needs skilled nursing or rehabilitation staff to manage, observe, and evaluate his or her care. Examples of skilled care include changing sterile dressings and physical therapy. Care that can be given by non-professional staff isn’t considered skilled care.
If you are considering nursing home care, you can begin your search at www.medicare.gov. You can find many links that can help you gather information about Medicare and Medicaid-certified nursing facilities and long-term care options in your state. You can also compare the quality of nursing homes in your area. To look at or print a copy of the booklet “Medicare Coverage of Skilled Nursing Facility Care,” go to “Search Tools” and select “Find a Medicare Publication.” You can also call 1-800-Medicare (1-800-633-4227) (TTY users 1-877-486-2048) to find out if a free copy can be mailed to you.
Nursing Homes: Nursing homes serve as permanent residences for people who are too frail or sick to live at home because of physical, emotional, or mental problems. Nursing homes provide a wide range of personal care and health services, including helping people with dressing, bathing, and using the bathroom. Nursing home residents usually require daily assistance.
Here are some questions to ask when considering choosing a nursing home. As a caregiver, you may want to make surprise visits at different times of the day to verify conditions.
- Is the nursing home Medicare- or Medicaid-certified?
- Does the nursing home have the level of care needed (such as skilled or custodial care) and is a bed available?
- Does the nursing home have special services if needed in a separate unit (such as a ventilator or rehabilitation) and is a bed available?
- Are residents clean, well groomed, and appropriately dressed for the season or time of day?
- Is the nursing home free from strong, unpleasant odors?
- Does the nursing home appear to be clean and well kept?
- Does the nursing home conduct staff background checks?
- Does the nursing home staff interact warmly and respectfully with home residents?
- Does the nursing home meet cultural, religious, and language needs?
- Are the nursing home and the current administrator licensed?
Nursing home care can be very expensive. Medicare generally doesn’t cover nursing home care. There are many ways people can pay for nursing home care. For example, they can use their own money, they may be able to get help from their state, or they may use long-term care insurance.
Many types of health insurance do not cover nursing homes. Most people who enter nursing homes begin by paying for their care out of their own pocket.
In some cases, Medicaid may pay for long-term care costs for individuals who meet eligibility requirements. Medicaid is a state and federal program that pays most nursing home costs for people with limited income and resources. Eligibility varies by state. Medicaid will pay for nursing home care only when provided in a Medicaid-certified facility. For information about Medicaid eligibility, call your state Medical Assistance (Medicaid) Office.
If you have questions about Medicaid, you can call your State Medical Assistance (Medicaid) office for more information. You can also visit www.medicare.gov for helpful phone numbers and websites. Or call 1-800-Medicare (1-800-633-4227) (TTY users 1-877-486-2048).
Hospice care is a special way of caring for people who are terminally ill (dying). Hospice care includes treatment to relieve symptoms and keep the individual comfortable. The goal is to provide end-of-life care and relieve pain, not to cure the illness. Medical care, nursing care, social services, durable medical equipment, and drugs for the terminal condition and related illnesses can be a part of hospice care.
Most hospice patients get hospice care in the comfort of their home and with their families. Depending on the patient’s condition, hospice care also may be given in a Medicare-approved hospice facility, hospital, or nursing home.
Medicare’s hospice benefit provides support and comfort to beneficiaries who are dying, including services not usually covered by Medicare. Hospice volunteers are available to do household chores, provide companionship, allow the caregiver time off to do tasks outside of the house, and offer support to the patient and family. Medicare also pays for inpatient respite care (short term care for hospice patients) so that the usual caregiver can rest.
To be eligible for hospice care, the beneficiary must have Medicare Part A (hospital insurance) and:
- The doctor and hospice medical director must certify that the beneficiary is terminally ill and has probably six months or less to live.
- The beneficiary must sign a statement choosing hospice care instead of routine Medicare-covered benefits for their terminal illness.
- The beneficiary must receive care from a Medicare-approved hospice program.
Medicare hospice benefits do not include treatment to cure terminal illness. If the beneficiary’s health improves or the illness goes into remission, he or she always has the right to stop getting hospice care and go back to the regular Medicare health plan. A hospice patient will continue to have Medicare benefits to help pay for treatment of conditions unrelated to the terminal illness.
Here are questions you may wish to consider when selecting hospice care providers:
- Does the hospice provider train caregivers to care for the beneficiary at home?
- How will the beneficiary’s doctor work with the doctor in the hospice program?
- What is the patient-to-staff ratio?
- Does the hospice staff meet regularly with the beneficiary and family to discuss care?
- How does the hospice staff respond to after-hour emergencies?
- What measures are in place to ensure hospice care quality?
- What services do hospice volunteers offer? Are they trained?
- Is the hospice program certified and licensed by the state or federal government?
To find a hospice program, call 1-800-Medicare (1-800-633-4227) (TTY users 1-877-486-2048) or your State Hospice Organization in the blue pages of your telephone book.
This article is for informational purposes only. Nothing in it should be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.
From time to time, Medicare rules and guidelines may change, so always verify such information directly with your Medicare plan.