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Where to Start
A Primary Care Doctor Who Understands the Needs of Older Patients
 Specialized Geriatric Services
 Record Keeping
Hospital Stays
General Information and Resources for Health Care Insurance
Health Care Insurance Coverage: Medicare, Medigap & MassHealth
Basic Medicare Coverage
Supplements to Medicare: Medigap Insurance and Medicare HMOs
Supplements to Medicare: Options Available through MassHealth
Supplements to Medicare: Military Service Benefits
Prescription Drug Benefits
Long Term Care Insurance

One of the biggest challenges of elder caregiving shared by elders and their caregivers are concerns about how to stay healthy, how to secure health insurance coverage, and how to find healthcare providers who will best meet their needs. But a caregiver cannot do this all alone. Here are some ideas about how to build the knowledge and medical support you need.

Not every doctor who practices primary care has special knowledge in geriatrics. However, in managing the health care needs of someone 60 or older, it is important to have a primary care physician who:

Makes suggestions about staying healthy, such as modifications in diet and an appropriate exercise routine.

Makes recommendations about regular screening tests appropriate to each elder's health history, such as mammograms, bone density tests and stress tests.

Can work with you to coordinate all of your health care needs, particularly referrals to specialists and coordination among specialists.

Has substantial experience with conditions that are common for older adults such as heart disease, high blood pressure, diabetes, stroke, and osteoporosis.

Has a good reputation for prescribing appropriate medications and managing the interactive effects of medications on older people.

Is knowledgeable about home health services, and when to use them.

Often a primary care doctor, even one who is sensitive to the issues facing older patients, is not enough. check with your insurance provider, hospital, clinic or HMO (health maintenance organization) to find geriatric specialists in the following areas:

Geriatric assessment and evaluation


Fitness and exercise


Mental Health

Social work

Physical, speech and occupational therapy

Disease-specific specialties (i.e. diabetes)

Organ-specific specialties, (i.e. cardiology)

A very useful source of information on health concerns of particular relevance to elders is the American Geriatrics Society's Foundation for Health in Aging. This organization provides information on the special health care needs of older adults on its website American Geriatrics Society's Foundation for Health in Aging. On this website you will find general and specific illness information, news about current research and questions to ask your physician about your care. The organization can also be contacted at 800-563-4916.

When seeking specialized geriatric care, it is useful to prepare written questions about how and where care is provided, the qualifications of the providers, and what insurance coverage is accepted.

Most major hospitals in Massachusetts have geriatric specialty departments, and your primary care physician can help you locate specialists as well. If you would like assistance in researching and locating a physician, either for primary care or specialty care, the following organizations can help:

The Massachusetts Medical Society offers resources for consumers on their website at The Massachusetts Medical Society > For Patients, including a helpful guide called "How to Choose a Physician That Is Right for You," and a free physician referral service. For referrals, call 781-893-3800, extension 5515, during regular business hours.

The Massachusetts Board of Registration in Medicine offers professional profiles of physicians licensed to practice in the Commonwealth at: Massachusetts Medical Board or you can request a profile by phone at 800-377-0550 or 617-654-9800.

Many elders have multiple chronic health conditions. This means they have multiple doctors and multiple medications. This amount of information is very difficult to keep track of and keep up to date. One of the things that elder caregivers often do is to compile a list of names and phone numbers of all the health care providers involved in their elder's care, and a list of all the medications and appropriate dosages. There is also a need to keep records of phone conversations with doctors and other providers.

Some caregiver support organizations have anticipated these needs and have constructed guides to help caregivers communicate with health care providers, both primary care physicians and specialists, and manage health care information.

National Alliance for Caregiving has partnered with the National Family Caregivers Association to create a course they call "Family Caregiving 101" with useful tips for caregivers who are trying to collect and track health care information. Go to Family Caregiving 101 > How to Manage > Navigating the Health Care Maze.

Even with the best health care providers, many elders end up in a hospital sometimes called an "acute care facility." Hopefully the care provided will be of high quality and the length of stay will be appropriate to the problem that prompted the hospitalization.

Many people think that a caregiver's job starts when the patient is discharged, but any caregiver who has lived through this well tell you otherwise. Caregivers often play a critical role:

At the time of admission; describing the symptoms or precipitating incident;

During the stay: monitoring the quality of health care, medications, food and personal comfort; and

At the time of discharge: being part of planning for home care and other supports.

Hospitalizations are emotionally stressful for caregivers and pose their own particular challenges. One that is often unanticipated is having your elderly relative cared for by a doctor who is a "hospitalist" sometimes called an "inpatient specialist" -- who is unknown to the patient or the family.

What exactly is a hospitalist? Hospitalists are physicians trained and board certified in internal medicine -- sometimes called primary care who specialize in the care of hospitalized patients.

They serve as the physicians-of-record for inpatients, during which time they accept "hand-offs" of hospitalized patients from their primary care providers. This does not prevent the involvement of specialists, such as an orthopedic surgeon, seeing a patient who just had a hip replacement. Hospitalists return the patients back to the care of their primary care physician at the time of hospital discharge.

There are advantages and disadvantages to this system and it is helpful to be aware of both. On the positive side, hospitalists can rapidly coordinate inpatient care and react in real time throughout the day to clinical data and changes in patient's medical status. On the negative side, some patients and their families do not like having a new physician during an acutely stressful time. There may also be communication problems between inpatient physicians and the elder's primary care physician at the time of hospital admission and discharge something that can lead to additional stress for caregivers.

Finding good doctors is only half the battle. Finding the best health insurance, understanding Medicare coverage, and determining eligibility for particular health insurance programs, is the other half. And then there is the part no one talks about: putting all this together! It can be confusing and time-consuming to figure this out.

To start, it is useful to consult three organizations with fairly comprehensive information: SHINE (Serving the Health Information Needs of Elders) a resource provided by the state to assist elders and their caregivers by answering questions about Medicare, Medicare supplements, Medicare Part D (drug coverage) Medicare Health Maintenance Organizations, Medicaid, free hospital care, prescription drug assistance programs, drug discount cards, and long-term care insurance.

By going to Mass.Gov-SHINE you can access a Directory with information by city and town.

National Council on Aging provides a Benefits Check Up on its website a fast, free, and confidential screening tool to determine eligibility for nearly 1,000 unique state and federal programs as well as detailed instruction on how to apply for these programs: National Council on Aging-Benefits Checkup.

Medicare Rights Center is an independent source of state-specific information on medicare and other health care coverage issues. It provides very useful information on the website: Medical Rights Organization, and a list of telephone hotlines for all states. Massachusetts residents can call toll-free in state: 800-882-2003, TTY: 800-872-0166.

Medicare is a federal health insurance program for people age 65 or over and is the major insurer of health care for elders and certain disabled people. However, it includes various programs with different requirements for different purposes and different groups of people, and it is important for elders to have a clear understanding of the Medicare system. For extensive information about Medicare contact: Medicare.Gov or call 800-633-4227. What follows is an outline of its major components.

1. Hospital Insurance (Part A) helps pay for medically necessary inpatient hospital care, some home health services and certain short-term stays in a skilled nursing facility (nursing home) once Medicare criteria have been met.

2. Medical insurance (Part B) helps pay for necessary doctor services, outpatient services and supplies.

3. Coverage for home health services applies to the full-approved cost of the services if four defined condition are met, and anyone seeking this coverage should check with a physician to determine if all of the necessary condition exist in the particular case. The conditions are:

The needed care includes intermittent skilled nursing care, physical therapy, or speech therapy.
The individual receiving care is confined to home.
The individual is under the care of a physician who determines the need for services and establishes a plan of home health care.
The home health agency providing services participates in Medicare. Services covered by Medicare include nursing, physical occupational and speech therapy.

Individuals and their caregivers should speak with their physician to determine whether services can be received under the Medicare home health benefit.

There are two ways for adults over 65 to supplement their health coverage if their incomes place them above the eligibility criteria for subsidized health care: one is a Medigap Policy and the other is a Medicare HMO. A Medigap Policy is health insurance sold by private companies to fill in the gaps or supplement what is available through basic Medicare. These policies must follow federal and state laws and have certain standardized benefits so you can compare them, and costs do vary. These policies may cover such things as co-payments for out-patient visits, deductibles for hospitalization, skilled nursing facilities, mental health benefits, and other specialized services. Medigap insurance plans must meet Massachusetts Division of Insurance policy standards for private insurance companies.

To buy a medigap policy you must be enrolled in Medicare Part A and Medicare Part B. Two standard Medigap plans are now available in Massachusetts:

Medicare Supplement Core

Medicare Supplement 1 (no outpatient prescriptions drug coverage.)

Note: Previously, there was a medigap plan called "Supplement 2," however, prescription drug coverage through this plan is available only to people who were enrolled before 12/31/05. There is more on prescription drug coverage on Prescription Drug Benefits, Section 3, Part 2.

For further information about Medigap:

Call 800-AGE-INFO (800-243-4636) and choose the option "for health insurance questions or to reach a SHINE Counselor."

See the "Massachusetts Bulletin for People with Medicare" issued on the website: Executive Office of Elder Affairs > Consumer Guides > Medigap/HMO.

Another way for some elders and some caregivers to supplement their health coverage is through enrolling in a Medicare HMO.

A Medicare HMO is an HMO that has contracted with the federal government under the Medicare Advantage Program (formerly called "Medicare + Choice") to provide health benefits to people who are eligible for Medicare but choose to enroll in the HMO, instead of receiving their benefits and care through Medicare.

Medicare HMOs provide these services under contract with the federal Centers for Medicare & Medicaid Services (CMS). HMOs provide care through their own networks of hospitals and doctors that provide members with health services.

The additional benefits provided by Medicare HMOs (that are not covered by Medicare) include preventative care, limited prescription drug coverage, dental care, hearing aids or eyeglasses. HMOs may have additional costs beyond your monthly insurance costs such as co-payments for services.

Medicare HMOs are sometimes available through current or former employers and military service. To find out if this is an option contact previous employers and/or the Veteran's Administration. To find your local Veteran's Agent, go to Mass.Gov-Local Veteran's Agents.

MassHealth is the name of the Massachusetts Medicaid Program. It is a state and federal program that provides access to medical benefits for low-income children, families, disabled individuals and persons over age 65 who meet eligibility requirements. For those who are low-income elders and may not be able to afford a Medigap policy or enroll in a Medicare HMO, MassHealth provides these programs to help supplement Medicare:

1. Senior Care Options is a managed care program providing comprehensive, multi-speciality care covered by Medicare and MassHealth. The program covers most needed services provided by physicians, dentists, hospitals, clinics, medical equipment suppliers and therapists. Also included are some home services, X-rays, laboratory tests, prescription drugs, dentures and eyeglasses.

Information about the program and eligibility is available from Mass.Gov-For Consumers.

2. Program of All-inclusive Care for the Elderly (PACE) Participants receive all of their health, medical, rehabilitation, social, and support services and health insurance for one monthly fee. The program enables frail elders to remain independent in the community and in their own homes. To determine eligibility for PACE and whether there is a program in your area contact the MassHealth Enrollment Center at 800-408-1253, TTY: 800-231-5698 for a MassHealth Application and more information about this program.

3. Long Term Care Medicaid is a component of MassHealth that pays for nursing and other medical services for financially eligible individuals residing in nursing facilities, rehabilitation hospitals and state hospitals. Eligible persons must be age 65 or older or disabled with medical and financial needs based on standards set by the Social Security Administration. Applicants for this coverage are screened to determine that there is a medical need for skilled nursing care that cannot be met in the community.

4. MassHealth Buy-In is a program authorized by Congress for persons who are eligible for Medicare, allowing MassHealth to pay all or part of the Medicare Part B premium for Massachusetts residents who are not getting other MassHealth benefits if a person has only Medicare Part A but meets financial eligibility guidelines.

For information about MassHealth programs and current income requirements, or to request an application, call MassHealth at 800-841-2900 or 800-497-4648 (TTY), or SHINE at 800-AGE-INFO (800-243-4636).

Veterans Programs Some elders (and family members) may be eligible for health care coverage through the Veteran's Administration (VA) or the Department of Defense (DoD) if they have served in the military or, in some cases, have been on active duty while in the National Guard. There are two major programs.

1. TRICARE The DoD provides coverage through TRICARE (formerly known as CHAMPUS) to active duty and retired military persons and their dependents. TRICARE healthcare coverage is also provided for some in combination with Medicare Parts A & B. Detailed information about specific TRICARE eligibility and coverage is available at TRICARE or by calling Health Net Federal Services (HNFS) at 877-TRICARE (877-874-2273).

2. CHAMPVA The Veterans Administration health care coverage is provided through CHAMPVA to veterans and their dependents who meet one of the eight categories of eligibility. Detailed information is provided about eligibility for VA health benefits on the U.S. Department of Veterans Affairs website at U.S. Department of Veterans Affairs or by calling VA Benefits to learn about all VA benefit information: 800-827-1000, or for information specifically about health benefits call 877-222-8387.

Some people are eligible for healthcare coverage through CHAMPVA and TRICARE; however, making a decision to change benefit coverage between these two programs within a specific episode of care may result in denial of payment from either program. For more information about how this works contact the TRICARE "Beneficiary Point-of Contact" at your regional VA facility.

If you are eligible for TRICARE coverage you should check with the VA Department at 800-827-1000 to locate a VA Medical Center that participates in TRICARE because not all VA Medical Centers participate in the TRICARE network. VA Medical Centers that participate in the TRICARE network will provide treatment for a non-service related disability if space is available. In many cases homecare services to manage daily living tasks are covered by the VA; however, eligibility for these services varies so you should call 877-222-8387 to determine whether your eligibility covers these services through the CHAMPVA program.

Since the 2006 Prescription Drug Benefit has been available, the number of questions and the general confusion around this already controversial topic has escalated. Here is some basic information to help you find your way among the new options.
Medicare Prescription Drug Coverage (Part D) A number of plans are available and elders and caregivers should assess them carefully in relation to the specific needs of the person insured. The list of Prescription Drug Plans in Massachusetts can be accessed at this address, PDP Landscape, or Medicare.Gov > Prescription Drug Plan > Landscape of Local Plans > Massachusetts > PDP (or Stand-Alone Prescription Drug Plan) (Note for PDP Landscape: Each state has its own PDP Landscape document.)

The requirements of the system call for subscribers to choose a prescription drug plan and pay a monthly premium of about $35. With respect to specific drug purchases:

The subscriber pays the first $250 (called a "deductible").

Medicare then will pay 75% of costs between $250 and $2,250 in drug spending.

The subscribers pay 100% of the drug costs above $2,250 until $3,600 in out-of-pocket spending is reached.

Medicare will pay about 95% of the costs after the subscriber spends $3,600.

There are two programs available for low income elders to help cover prescription drug costs.

Prescription Advantage is a drug insurance program run by the Commonwealth's Executive Office of Elder Affairs for Massachusetts residents age 65 and older, and younger individuals with disabilities who meet income and employment guidelines. Prescription Advantage will provide supplemental assistance to Medicare Part D coverage based on income. It may help pay all or part of the Medicare prescription drug plan's monthly premium, deductible and drug co-payments. Prescription Advantage will also provide an out-of-pocket spending limit. Once this limit is reached, it will cover drug co-payments for the remainder of the plan year. Information about Prescription Advantage and other options for reducing the cost of prescription drugs is available from the SHINE WEBSITE Medicare Outreach > help for Elders Buying Prescription Drugs, or by calling 800-AGE-INFO (800-243-4636) or TTY 877-610-0241.

These organizations can provide additional information regarding prescription drug coverage:

SHINE provides extensive information on its website about Medicare Part D. You can call 800-243-4636, or go to their website and follow the arrows: Medicare Outreach Organization > SHINE Documents and Charts > Medicare Prescription Drug Bill Information (Medicare Part D.)

MassMedline has pharmacists available who can be helpful in your selection of the Medicare prescription drug plan that best meets your needs based on the medications you take. Contact Mass Medline, or call 866-633-1617 between 8 AM-6 PM. (The toll-free TYY number can be obtained from the MassMedline operator.)

NeedyMeds.com is a non-profit organization that has information on over 1000 programs that help those who can't afford their medications and/or health care expenses. Web site: NeedyMeds.com, or call 215-625-9608.

This kind of insurance is becoming increasingly popular as the population ages and as many caregivers are dealing with their own health care needs at the same they are providing care to elders.

Long term care policies can vary greatly from one insurer to the next. Policies may include benefits for care in a nursing home, in an assisted living facility, in your home, or in an adult day care center. Some policies may pay for family benefits, such as caregiver training, but do not pay for services provided by family members.

It is important to determine what types of care are covered by any long-term care policy you are considering. Policies that limit coverage to care provided in a nursing home will not generally pay for services you receive at home.

More flexible policies are available which allow you to use benefits to cover any necessary long-term care in any setting, but these policies usually are more expensive than policies that limit the types and settings of services covered. Detailed information about long term care and long term care insurance is available in a Guide provided by the Massachusetts Division of Insurance. See Mass.Gov and type "long term care insurance guide" in the search box at the top. Publications are available free as a PDF document. Or call the Division of Insurance at 617-521-7777.

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