by Rose Broyles

For the past few years, my sister and I have been at our wit’s end trying to find ways to ensure the stability of our parents’ financial, emotional and physical well being. We drive everyone crazy talking about the same problems and possible solutions! It was very difficult for us because had we had the choice, our parents would have stayed in their own home. But because they lived in a 2-story town home, it was physically impossible. So, on they went from home to an apartment, to assisted living to board-and-care, our mom to a nursing facility,  and then both reunited in  a rented home where they have been for the past year and a half. Is this their permanent residence? Probably not. But it’s been the most stable of all of the above. Unfortunately, a majority of their expenses are out-of-pocket because my dad still gets a pension which makes he and my mom ineligible for Medicaid.

Most of us familiar with Medicaid are under the assumption that it ONLY covers skilled nursing homes after the patient has exhausted all financial assets. Of course, this isn’t entirely true, but I’ll save that for another post specifically on Medicaid. However, there is a little glimmer of hope in alternatives which is offered with limited access through Medicare. There are two programs: PACE and Social Managed Care Plan. Unfortunately, for PACE, we do not live in the areas covered, but hopefully they will provide that service in San Diego soon. You may want to read below to see if you or your loved one lives in the covered area. 

PACE (Program of All-Inclusive Care for the Elderly) 

What is It

It is an optional benefit under both the Medicare and Medicaid programs that focuses entirely on older people, who are frail enough to meet their State’s standards for nursing home care. Medical and social services can be provided at an adult day care center, a facility or at the enrollee’s home. For most patients, the comprehensive  service packages enables them to continue living at home while receiving services.  PACE is only available to states who have chosen to include it under Medicaid. 

Eligibility

• Must be 55 years of age or older
• Live in the PACE service area
• Submit to a screening by a team of healthcare professionals to assess eligibility
• Be able to live safely in a community environment at time of enrollment. ** you may want to inquire about this one, because if the patient chooses to stay at home, this may be irrelevant.

Services

• PACE offers and manages all of the services provided to enrollees to help maintain their independence. 
• Health team maintains frequent contact with enrollee to adapt program to changes in health or needs
• Services include: medical, social, rehabilitative, personal care, restorative services, etc.

Payment

• PACE receives a fixed payment per enrollee from Medicare and Medicaid. The amounts remain the same throughout the year regardless of services provided.
• Enrollees may have to pay a monthly minimum  depending on their eligibility for Medicare and Medicaid.

Find a Service provider

PACE Providers

Downloads

Download a PACE Fact Sheet here.

Social Managed Care Plan

This is an organization that provides a full range of Medicare benefits plus additional services such as: care coordination, chronic care benefits, prescription drugs, homemaker, personal care services, medical transportation, adult day care, and respite care. 

Unfortunately, there are only four available plans. 

Kaiser Permanente, Portland -Oregon

Requirements:

• 65 years +
• Have Medicare Parts: A and B ; continue to pay Part B premium
• Live near KP service area
• Cannot have end stage renal disease, or live in an institutional setting
• Long-term care benefits require visit from resource coordinator to assess needs.

SCAN, Long Beach – California

Requirements:

• 65 years + 
• Have Medicare Parts: A and B ; continue to pay Part B premium and live near SCAN’s service area.
• Cannot have end stage renal disease
• Extended home services require a nursing home certificate which indicates that a member of an informal system like a relative is not sufficient to keep the patient out of a nursing facility.

Elderplan, Brooklyn- New York

Requirements

• 65 years +
• Have Medicare Parts: A and B ; continue to pay Part B premium and live near Elderplan’s service area.
• Cannot have end stage renal disease
• Enrollee must meet state requirements for nursing home certificate.

Health Plan of Nevada, Las Vegas- Nevada

Miscellaneous

Download the Medicare and Home Healthcare Booklet here.

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