Glossary:

Managed Long Term Care Program

The Managed Long-Term Care program was created in 1997 specifically for seniors who are physically qualified to enter a nursing home, but who prefer to remain in their own homes. Under this program, members are eligible for all of the care that is available under the Lombardi program, but can also receive a wide range of additional services. VNS CHOICE is an example of a Managed Long-Term Care Program.

Medicare Part A

The Medicare component that provides insurance to cover the costs of home health care after hospitalization, hospice care, plus inpatient hospital services, nursing home care, or other extended facility care.

Medicare

Medicare is a national health insurance program designed primarily for seniors. Medicare is provided by the U.S. federal government; virtually every permanent resident of the United States who is 65 or older is eligible for Medicare, even non-citizens. There are two parts to Medicare, Part A and Part B. Part A pays for hospitalizations and for limited home and nursing home care. Part B pays for physicians, lab tests, and outpatient hospital care. There is a premium associated with each program. Part A premiums are waived for those who have fulfilled certain eligibility requirements (most permanent residents who have worked steadily in the United States and their spouses are eligible). Part B premiums ($93.50 per month in 2007) must be paid by anyone who wishes to be covered under that portion of the Medicare program.

While Medicare covers the majority of most hospital and physician expenses, it also expects beneficiaries (Medicare’s term for those it covers) to pay for a share of these expenses. For example, you pay $992 for days one through 60 of a hospital stay. The cost rises for each day after that. Medicare beneficiaries have a $100 deductible for physician expenses as well as 20 percent co-pay for all such expenses.

For patients in a nursing home (immediately following a hospital stay), Medicare covers the first 20 days and requires beneficiaries to pay $124 per day for the next 80 days. Medicare does not cover days in a nursing home beyond 100. CHHA’s can provide medical home health services such as intravenous drugs, artificial feeding and hydration, oxygen therapy, nursing visits for wound care, injections, catheterization, colostomy care, administering oral medications, skilled therapy and some services of a home health aide.

Medicare Part B

The Medicare component that provides benefits to cover the costs of physicians’ professional services, whether the services are provided in the physician’s office, a hospital, a nursing home or the Medicare patient’s home.

Medicare Prescription Drug Plan (DPD or MPDP)

A drug plan offered by insurance companies to beneficiaries of the Original Medicare Plan (Part A and Part B), to beneficiaries of Medicare Private Fee-for-Service Plans that don’t offer prescription drug coverage, and to beneficiaries of Medicare Cost Plans that do offer Medicare prescription drug coverage.

Medigap

Medigap insurance was designed to pay for many of the gaps in Medicare coverage. Ten kinds of Medigap policies are legally available in most states, including New York State. The number of policies actually available in a given part of New York State varies, however, with the insurers who offer such policies in a given county. Most popular Medigap policies cover Medicare’s hospital and physician deductibles and pay for some home health care in addition to that which is covered by Medicare.

Medicaid

Medicaid is a program funded jointly by the federal and state (and in some cases, city) governments. In New York, it is administered by New York State. People of all ages whose income and assets fall below a specified level can qualify for Medicaid coverage. Medicaid provides comprehensive medical coverage for all of its recipients, but because many health care providers do not accept Medicaid, access to medical care is often limited. For adults over the age of 65, the picture is somewhat different; these adults are generally covered by Medicare, and the vast majority of health care providers accept Medicare. Those who accept Medicare often also accept Medicaid for their older patients. In these cases, Medicaid provides coverage that fills the gaps in Medicare, while Medicare continues to provide basic medical care benefits.

For older adults who qualify for Medicaid, there are many other available services. Programs such as Managed Long-Term Care (VNS CHOICE) and Long-Term Home Health Care provide comprehensive home care for those who are covered by Medicaid. There are essentially two levels of Medicaid eligibility. One is for community-based care, and the other is for nursing home care. In order to qualify for Medicaid in New York State in 2007, an individual senior’s adjusted income cannot exceed $700 (or $900 including a spouse) per month. The income of a legally responsible relative who lives in the household is also considered.

Income is calculated by deducting certain “allowable” expenses. Perhaps the most significant adjustment is one for specific kinds of “medical” expenses. For example, if someone spends $1,000 per month on medical expenses like home health care and that person has an income of $1,700 per month, he or she has an adjusted income of $700. Consequently, such a person may qualify for Medicaid, even though his or her unadjusted income significantly exceeds the Medicaid maximum of $700 per month.

There is also a limit on the assets one may possess and still qualify for Medicaid. Assets may not exceed $4,200 for an individual (or $5,400 including a spouse) excluding the value of the person’s primary residence, an automobile, and a $1,500 burial fund. A spouse’s assets may or may not be considered, depending on the circumstances. Only assets that exist on the day a Medicaid application is filled out are considered when one is applying for community-based programs. When applying for nursing home coverage, assets owned within the 36-month period prior to applying for coverage affect eligibility.