“She had the best of care for five months,” says Turner, a District resident. “A hospice licensed practical nurse came first thing in the morning to help change complex dressings, a primary nurse visited several times a week, there was an on-call nurse to help address pain-control questions in the middle of the night, plus a social worker and a chaplain. It took all of us to get through those weeks.”

Still, Turner tells families, she had to bear much of the caregiving, even taking a leave of absence from her job. “I treasured that time, but it was physically and emotionally exhausting. Hospice made it doable, but the truth is, it was still a lot of hard work.”

Some families, she says, may not be able to bear that burden, certainly not without hiring extra help. But, she says, “the hospice gave me the skills and confidence to do what I wanted so badly to do for my mother. I will always be grateful.”

Introduced to the United States in the 1970s, hospice care is becoming an increasingly common treatment. Last year, 1.65 million people received hospice care, up from just more than 1 million in 2004, according to the National Hospice and Palliative Care Organization. In addition, there were more than 5,500 programs in the U.S. last year, compared to 3,100 in 2000.

Although the growth in hospice programs has given patients and their families more choices than ever, a recent into the industry found widespread concerns about the quality of care. The Post cited numerous complaints, noting that although hospices are supposed to provide continuous nursing care to patients whose pain or symptoms are out of control — commonly called “crisis care” — one in seven do not.

Unfortunately, there is no federal rating system — as there is for hospitals and nursing homes — that can help consumers make educated choices about the hospice they select.

For many families, hospice is an unfamiliar concept that prompts fear and questions, including where, why and even when someone should receive hospice care. To help patients and their caregivers, here are some hospice basics:

What Is Hospice Care?

Hospice is not a particular place, like a hospital, but a service that provides end-of-life care and support to the dying and their families, most often in a patient’s home. By signing up for hospice, patients generally agree to stop all disease-fighting treatments, such as chemotherapy and radiation, although some hospices allow such therapy if it is to help manage symptoms, such as pain or problems breathing.

One of the hospice’s primary goals is to alleviate pain. Through a team of caregivers — doctors, nurses, social workers, grief counselors, spiritual counselors, home health aides and volunteers — the hospice provides comprehensive care, including drugs, medical supplies and equipment. It instructs families on patient care and even provides special services such as physical therapy and psychological counseling.

“If we can manage and alleviate pain, we can help reinvigorate patients to help them accomplish whatever it is they want to do in their remaining days, whether it’s making peace with an estranged sibling, attending the wedding of their grandchild — or just going out to eat or fish,” says Malene Davis, president of Capital Caring, one of the first hospices in the Washington area. It now cares for about 1,200 patients a day.

How Much Care Does Hospice Provide?

Comprehensive care generally does not mean around-the-clock service, although many hospices provide 24/7 care when the patient is in crisis or near death.

“The hospice will teach families how to care for a patient, address their concerns and answer questions, but it does not take over the caregiving,” says Dale Lupu, an associate professor at George Washington University’s Center for Aging, Health & Humanities. “Someone on the hospice staff should be available by phone 24/7 in case there’s a crisis. But for hour-by-hour, day-to-day care, the family has to figure out a way to be involved,” even if it means hiring a private nurse or home health aide.

That’s one reason why hospice care may not be for everyone. “Families have to look within themselves and ask if they are comfortable being part of the dying process,” says Linda Kunkel, director of marketing and business development for Care Options, a Northern Virginia care-management firm. “It can be very gut-wrenching and, for some people, very hard.”

Who Pays For Hospice Care?

Medicare covers most hospices for its beneficiaries. Private insurance plans and HMOs also generally pay for hospice care, but they may have a preferred provider. Check with your insurer before you begin your hospice search.

In some cases, a small co-pay — such as $5 or 5 percent — may be required for medication, inpatient facility care and/or respite care.

Additionally, most hospices offer financial help for families in need. So make sure to discuss any financial concerns in your initial meetings.

If Hospice Is Not A Place, Where Do I Get Hospice Care?

Nearly two-thirds of hospice patients die at their homes, a nursing home or an assisted-living facility.

For patients who can’t be cared for at home — perhaps they live alone or have complications that can be treated only at a health-care facility — some hospices have inpatient facilities in freestanding centers or specially designated sections in hospitals or nursing homes.

Why Would I Want Hospice Care? Can’t My Doctors And Local Hospital Adequately Meet My Needs?

Surprisingly no, hospice experts say.

“The traditional medical approach is cure, cure, cure; but when a person is dying, he or she may need a different approach,” says Linda Adler, head of Pathfinders Medical, a California health-care advocacy firm that helps patients with complicated medical diagnoses. “The patient needs someone who’s willing to move the conversation from finding a cure to having best quality of life in the midst of an illness, someone who’s not afraid to talk about the end of life and provide compassion in the final days. Most physicians aren’t trained to do that.”

Hospice caregivers also have in-depth training and experience in palliative treatments for pain management. “Most doctors are not adequately trained in pain management, and the quality of pain control in hospitals and nursing homes is very uneven,” says Naomi Naierman, who was the president of the American Hospice Foundation before it closed last year.

When Should I Start To Think About Hospice?

Most hospices require an order from the patient’s physician as well as approval from the hospice medical director. Both must certify that the patient has six months or less to live if the illness runs its normal course. However, if a patient outlives that time, he or she can be “recertified” to continue receiving hospice care.

But experts in end-of-life care say most Americans need to start thinking about hospice long before the final six months is near. As the American Cancer Society notes on its website: “One of the problems with hospice is that it’s often not started soon enough. Sometimes, the doctor, patient, or family member will resist hospice because he or she thinks it means you’re ‘giving up,’ or that there’s no hope. This is not true. If you get better or the cancer goes into remission, you can leave hospice and go into active cancer treatment.”

Indeed, hospice experts say many people leave hospice, a situation that the late humorist Art Buchwald made famous when recounting his own discharge from a hospice. Patients can then be readmitted to hospice when their conditions deteriorate again.

J. Donald Schumacher, president of the National Hospice and Palliative Care Organization, says patients should discuss hospice options as early as they are diagnosed with a potentially fatal disease. “Don’t wait for the doctor to begin the conversation. Even if you agree to aggressive therapy, ask what are the plans if you don’t return to your optimum health.”

Are All Hospices The Same?

No; they vary greatly.

An increasing number of hospice organizations are for-profit, a distinct change from the early days of the hospice movement when they were mostly nonprofit. Today, 65 percent of hospice organizations are operated as for-profit companies, up from 34 percent in 2000.

Being a for-profit company is not inherently bad, but many of the complaints about substandard service have been leveled at for-profit hospice firms, The Post investigation found. The Post reported that the typical for-profit spent less on nursing and was less likely to have sent a nurse in a patient’s last days of life.

Still, Adler of Pathfinders Medical says consumers shouldn’t necessarily refuse to use a for-profit concern. “There are bad hospices, just like there are bad doctors” in both for-profit and nonprofit organizations, she says. “There are also great hospices in both kinds of groups. That’s why people need to do their homework.”

How Do I Find A Good Hospice?

First, seek recommendations from health-care providers and specialists such as geriatric-care managers. Ask which hospice they would use for themselves or a loved one.

Next, call the recommended hospices and ask questions about the issues that matter most to you, such as:

— How often do their caregivers come to visit? (A nurse’s aide should visit about three times a week and a nurse or doctor once a week, Naierman says.)

— Are their doctors and nurses certified in palliative care?

— Is there crisis care? How fast can a caregiver get to your home in case of a crisis? Will they come at any time, even 3 a.m. Saturday?

— Will the patient’s primary doctor still be involved in the medical care?

— Will a nurse or clinician be in the home when the patient is actively dying? (“The answer should be yes,” Naierman says. “If it is anything but yes, run, don’t walk, away.”)

— Is there an inpatient facility if the patient needs extra care? Is it conveniently located?

— Are there limits on radiation and chemotherapy, even if it’s to control pain? What about IVs, dialysis or blood transfusions?

— How does the hospice handle new health problems that are curable, such as urinary tract infections or pneumonia?

— What is expected from family members? What will they be required to do? Give medicine, including shots? Bathe the patient?

— Is respite care – providing relief and time off for caregivers – offered?

“Having a conversation with the hospice admission people helps you get a feel in advance on how receptive they will be to your needs,” says Naierman, who helped develop to ask a hospice.

Are There Any Other Criteria To Judge The Quality Of A Hospice?

Yes. Here are some details to look for:

— Accreditation status. Three organizations — the Joint Commission, the Accreditation Commission for Health Care and the Community Health Accreditation Program — inspect and approve hospice programs.

“I would always lean toward an accredited program when available because it speaks to a program’s willingness to open itself to review and, hopefully, improvement,” says Lupu, who notes that only 40 percent of hospices are accredited.

— Age and patient load. “Experience — gained over time and gained over a number of cases — usually helps build both individual clinician expertise and organizational/team expertise,” Lupu wrote in a , a blog about hospice and palliative medicine. “Very new and very small hospices are unlikely to have the breadth of experience and the depth of resources to assist with challenging or unusual circumstances.” She suggested that patients should generally lean toward an organization with at least five to 10 years of experience that handles at least 80 patients a day.

— “Live discharge rates,” which is the proportion of people who leave hospice care before dying. A large number of departures may signal that patients were unhappy with care and services. “I’d select a hospice with a live discharge rates in the 10 to 20 percent range,” Lupu says.

Where Can I Go For Additional Help?

There is a lot of information on hospices on the Internet, including:

— The website and its page.

— The American Hospice Foundation’s educational .

— The on hospice care.

— The Washington Post’s .

This article was produced by Kaiser Health News with support from .

This <a target="_blank" href="/aging/learning-about-hospice-should-begin-long-before-you-are-sick/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This KHN story was produced in collaboration with

Call it a wonky version of “American Idol” — or, perhaps more aptly, “Research for a Cause.” Four Georgetown University Medical Center scientists recently delivered 15-minute sales pitches about their work, hoping to win money from an unusual panel of judges: local residents who are not experts on science.

The first scientist showed cartoonlike drawings to explain how osteoporosis occurs. The second aired a video of a kidney transplant. The third projected a CT-scan image of the brain of a U.S. soldier severely injured in Iraq. The fourth displayed a photo of a tumor-ridden liver, a picture so graphic that she warned her audience that some might want to avert their eyes.

To become a judge, each individual agreed to donate at least $1,000 to the medical center. In return, the donor received a chance to review a handful of proposals by Georgetown researchers and vote for a top choice. The two projects garnering the most support each got a grant of $35,000. Donors also receive periodic progress reports on the studies and a tour of the labs.

The program, called Partners in Research, was launched by Georgetown in 2011 as part of an effort to develop new ways to finance biomedical research.

“Without a great track record or good preliminary data, it’s increasingly hard to win funding” from the National Institutes of Health or private foundations, says Vivien Marion, a senior director in the medical center’s office of advancement. In fact, the odds of winning an NIH grant have been steadily decreasing; in the past two years, less than 20 percent of applications have received funding, down from 30 percent 10 years ago as NIH’s budget for research grants has been flat while the number of applications has increased.

Partners in Research was designed to provide just enough funds to innovative projects to generate data that could “put researchers on a path to win more money” from other sources, says Marion, who runs the program and has contributed $1,000 to it each year.

This year, 59 partners donated $70,000; they selected their top funding choices last month.

This year’s winners were a project that explores new strategies to prevent osteoporosis and one that examines whether a drug used to treat hypertension and diabetes can reduce damage caused by traumatic brain injuries. The runners-up: a proposal to evaluate a new technology that might help doctors determine if donor kidneys are healthy enough for a transplantation and a study to find new molecules in the lab that could block a protein associated with cancerous tumor growth.

“You feel bad that you can’t support them all,” said Bette Kramer, who hosted a wine-and-cheese party to recruit donors.

“I give to a lot of different causes,” said Kramer, a retired District resident. “But this is personally gratifying because it’s an exciting way to participate in what’s going on in science and medicine today. I view this like venture capital, as an opportunity to provide funds for scientists looking for a breakthrough.”

The partners program reflects a growing trend of raising funds through “crowdsourcing,” in which individuals pool multiple small donations for greater impact. Internet sites such as Kickstarter, for example, have raised money from a large number of participants to fund projects proposed by various start-ups and researchers. Other Web sites, including GiveForward.com, GoFundMe.com and YouCaring.com, have allowed patients to solicit money to help underwrite their medical costs.
For people who prefer personal contact with fellow donors, there are giving circles, where individuals meet to select charities to receive their pooled donations.

Partners in Research grew out of a Georgetown promotional campaign designed to generate donations. In 2009, the university launched Doctors Speak Out, a community education program that hosts discussions of health issues. At these quarterly luncheons, university scientists detail how their research touched on these issues.

Donations were not required, but they were not discouraged, either. Many attendees would make contributions, often designating the funds for two research on one of the topics discussed. “The money was so diluted, it didn’t make enough of a difference,” Marion says. Trying to create a bigger impact, she thought of the growing popularity of giving circles and hoped a similar concept could work for Georgetown’s biomedical research projects.

Support has remained steady. The first year, 63 partners raised $75,000, which was split among three projects. In 2012, 62 partners who raised $70,000, which was shared by two projects.

For researchers, it’s a competitive process just to win a spot on the presentation platform, with each proposal undergoing a peer review by other Georgetown researchers. The first year, a dozen projects were reviewed and five finalists selected. Last year, there were nine applications and four finalists. This year, 34 applications were winnowed down to a final four that went before the judges.

Still, the process is easier than seeking other funds. “There’s less red tape, and if you’ve got a new, innovative idea but no pilot data to support it, this program gives you an opportunity to start building data to support outside funding in the future,” said Adam E. Green, an assistant professor of psychology whose team won one of the first year’s awards, for research into Alzheimer’s disease. Now his group is writing applications for outside funding. “I’m not sure how else we would have gotten to this point,” he said.

Mark Burns is one of this year’s winners, for his work on brain trauma. “This first step is an important one that will allow us to test our principal hypothesis and enable us to generate the exhaustive preliminary data that is required to secure a large research grant,” said Burns, an assistant professor of neuroscience.

Similarly, the grant enables scientists to follow their research into areas not initially expected. Rebecca Riggins, an assistant oncology professor, said she was able to expand her study of a promising breast cancer drug when tests showed it was also effective at killing brain tumor cells. Without the Partners in Research  grant last year, Riggins said, “I’m not sure we would have been able to pursue the brain tumor research; all that work would have been an orphan.”

None of the researchers has obtained outside finding yet, but they are working toward it.

Researchers acknowledge that the competition before the judges might turn into a popularity contest, with those that have the most dynamic and/or sympathetic presentation winning the funds. But, Robert Clarke, dean for research at the medical center, said, “It really doesn’t matter. It’s all good science, so not a penny will be wasted.”

The winners cite an additional benefit: personal engagement with the donors. Says Nady Golestaneh, director of research in the ophthalmology department, says, “The money is very useful, nice, but the personal donor support makes us even more motivated in our research.”

This <a target="_blank" href="/news/american-idol-style-grant-funding/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This <a target="_blank" href="/aging/long-term-care-insurance-tips-sidebar/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This story was produced in collaboration with

In the last years of Martin Privot’s life, his family had to start selling his assets to pay for his nursing home costs. “He needed 24-hour care and couldn’t be left alone,” recalls his daughter Toni Footer. “My biggest fear was we would run [through his money] and wouldn’t be able to provide the care that he needed.”

Toni Footer with a photo of her late father, Martin Privot. She says his experience “reinforced my already strong feelings that long-term-care [insurance] is a necessity” (Bill O’Leary/The Washington Post).

Privot died in 2008, from post-surgical complications and other ailments, before all his assets were depleted. Yet Footer, 61, says her dad’s experience “reinforced my already strong feelings that long-term-care [insurance] is a necessity.” The Rockville, Md., resident says she pays about $2,500 every year for such coverage for herself. “It’s expensive — in fact, it’s gone up twice — but it’s worth every penny. It provides a peace of mind that my family won’t have to struggle to find money to pay for my care.”

Mary McClelland came to the opposite conclusion after seeing how her mother’s expenses were often deemed exempt from coverage.

Her mother, Ruth Mezick, purchased long-term-care, or LTC, insurance in 1990 at age 78 when she was in fairly good health, paying an annual premium of $2,827 until she died 11 years later. In her mid-80s, her health began to deteriorate, and she spent time in a nursing home, at home with help and in assisted living. But her policy — which promised to pay $100 a day — failed to cover much of those expenses because it kicked in only after she had been in one institution more than 100 days.

“She was never in one place long enough to qualify. She ended up getting about 10 days’ coverage, worth about $1,000,” says McClelland, who lives in Falls Church, Va. “That was a lesson to me; I decided it doesn’t always pay off.”

Mary McClelland found that many of her mother’s expenses were not covered by her long-term-care insurance plan (Bill O’Leary/The Washington Post).

The question of whether to get long-term care insurance bedevils consumers and their advisers. Unlike medical insurance, it is intended primarily to cover people who need assistance with so-called activities of daily living — for example, the care of a dementia patient or someone recovering from a broken hip. It can be expensive: Premiums range from $1,000 to $5,000 a year, depending on the age, sex and health of the purchaser as well as the extent of the coverage. And policy details can be confusing.

Even advocates acknowledge that it isn’t for everyone. Jesse Slome, executive director of the American Association for Long-Term Care Insurance, an industry group, sums it up well: “Long-term care is a universal issue facing all Americans who are getting older. But long-term-care insurance is not a universal solution.”

So how great is the need for such coverage? It depends on how you look at the data. “One in two Americans are likely to need long-term-care services sometime in their lives,” says Amy Pahl, a consulting actuary for Milliman Inc., a leading actuarial and consulting company. However, Pahl adds, of those who might need long-term care, about a third will not meet the most common deductible period of 90 days because they will either die or recover before then.

To determine if a long-term-care policy makes sense for you, it is important to understand how the coverage works and what’s available.

Don’t Think Medicare Will Cover You

Most standard health insurance plans do not cover long-term care. Nor does Medicare or insurance policies that supplement Medicare.

Medicaid, however, is the largest source of coverage for long-term care. The program pays for more than two-thirds of nursing home residents, according to  from the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

But Medicaid comes with significant limitations. The choice of facilities that accept Medicaid is narrow, and the program is restricted to people with extremely limited income and virtually no resources, which forces middle-income consumers to spend down their assets if they want to qualify.

“Medicaid is supposed to be a safety net, but unfortunately it rests just about a half-inch off the floor,” says Tom West, a Northern Virginia financial adviser and long-term-care expert.

Yet Kansas Insurance Commissioner Sandy Praeger cautions that long-term care policies may not be a good investment for some people. “It’s mostly a policy to protect your assets [so you don’t have to sell everything to pay for care] in case you get sick. If you don’t have assets to protect, then you shouldn’t be buying it.” But even those with few assets might consider some protection because it will allow them more flexibility than Medicaid if they need to choose a nursing home.

How The Coverage Works

Typically, a policy pays a fixed daily benefit ($150 is common) for a certain period of time (often three to five years) starting at a specified time (90 days is common) after the beneficiary becomes disabled. The policy covers nursing home expenses, assisted living charges or less costly in-home-care bills.

Many policies also allow the initial fixed daily benefit to rise 3 or 5 percent annually to keep up with health-care costs. The policyholder agrees to a premium that can increase only if the change is approved by state regulators. Such increases have occurred frequently in recent years and, as a result, once-flat premiums have risen sharply. So have nursing home costs, which averaged about $214 a day — or more than $78,000 annually — for a semi-private room last year, according to a national  by the insurer MetLife.

“Long-term care insurance keeps you from being dependent on the government or relatives and it provides liquidity, even for people who have a lot of assets,” says Rockville financial planner Arthur Stein. “You don’t have to rush and sell assets in a down market, like today’s, to cover health costs.”

As people’s needs have changed, long-term care policies have expanded to cover assisted living and home care; some new policies are flexible enough to anticipate technologies that don’t yet exist, such as robotic care.

“The policies have become very innovative,” says Slome. “Today you can go in and design coverage for particular needs and desires; you can even buy long-term-care insurance to enable you to get your care on a cruise line if you want it — and can afford it.”

Today’s policies can also allow couples to share benefits, so a husband and wife can each buy a shorter-term policy, for example three years of benefits. About 70 percent of coverage today is sold to couples, Slome said. If it turns out that the husband needs more than three years’ coverage, he can tap into his wife’s benefit pool. And in some policies, if the husband completely exhausts the couple’s coverage, the wife may still receive some nominal benefits if she needs care, too.

At the end of 2010, about 7 million Americans had long-term care insurance, according to LIMRA, an association of life insurance and financial service companies. About 422,000 new policies were written in 2010. About 56 percent were sold individually, with the rest sold through employer- or association-sponsored sales.

The 2010 health-care law has a provision creating a voluntary, long-term care insurance program. However, in October, the Obama administration announced it would not implement the provision (called the CLASS Act) because it was financially unsustainable.

According to Slome, the average age of the buyer is 57, with three-quarters of the policies written when purchasers are between 45 and 64.

When buying insurance, the younger the consumer, the lower the annual premiums. Today, according to Slome’s association, a 55-year-old couple in generally good health can expect to pay $2,675 a year for $338,000 of benefits; that figure would grow to $800,000 by the time they reach 80 if the policy contained a 3 percent annual compounded escalation clause. If they are 65, however, that same policy would cost $4,660 a year and grow to only $527,000 in coverage when they are 80.

For Washington area residents, even that coverage can be less than needed. , a comprehensive listing of retirement community, nursing home, assisted living and rehab facilities and home-care options in the area, puts the daily local cost per person of nursing home care at $235 to $304, or nearly $86,000 to $110,000 a year. Daily assisted living costs run between $108 and $162. (The SourceBook is owned by The Washington Post Co.)

Steep Rate Increases

One of the key concerns among consumers is the rise of premiums.

“It’s probably the most frequent complaint I hear,” says Praeger, who heads the National Association of Insurance Commissioners’ health and managed care committee. “The problem is, the older policies weren’t priced right to begin with. Companies expected about 8 percent of customers to stop paying their premiums, when, in fact the lapse rate is closer to 2 percent.” That meant the insurers had to cover more beneficiaries than they expected at a time when the economic downturn has meant less return
on their investments.

Praeger acknowledges that rate increase requests have posed a dilemma for insurance commissioners. “If we don’t give them the rate increase they need, the insurance carriers could become financially impaired, and that doesn’t help people,” she says. In fact, in recent years, a number of companies have stopped selling policies. As a result, she adds, it’s hard to turn the increases down.

The policies can be very complicated, and Praeger advises consumers to consult with their accountant, attorney or other trusted financial adviser before purchasing a policy. “It’s important  to understand what you’re buying, what the benefits are. It’s very complicated so work with someone you know and trust if you want to buy a policy.”

This article was produced by Kaiser Health News with support from .

This <a target="_blank" href="/aging/calculating-a-long-term-care-policy/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

(Illustration by James Fryer for The Washington Post)

?

Throughout Robert Joseph’s career, the Alvin, Texas, electrician always understood his health insurance policies. “I’ve never had a problem,” Joseph says, “until I tried to sign up for Medicare.”

The chief reason: Joseph didn’t sign up when he turned 65. He was still working, receiving health insurance from his employer. And when his company went bankrupt at the end of 2009 — Joseph was then 67 — he received 18 months of severance pay.

“On my last day of work, I went to the Social Security office, asking for some guidance,” recalls Joseph. He never spoke to an expert; instead, he says, he was handed a couple of forms to complete. He researched his Medicare handbook, which noted that “current” employees didn’t need to apply for Medicare. Since he continued to get monthly severance checks that deducted Medicare taxes and he was allowed to continue buying health insurance through the same carrier for the 18 months, he thought he could wait to join Medicare. He was wrong.

Medicare no longer considered him a “current” employee and said he should have enrolled within eight months of his layoff, not 18 months later. As a result, for the rest of his life, Joseph may have to pay extra on his monthly Medicare premium (10 percent for each year he delayed enrollment after his job ended). Even worse, Joseph will be without any insurance for a year. Under Medicare rules, he has to wait until the next open enrollment period, beginning in January, to sign up, and coverage won’t begin until July.

Joseph is not alone. “We’re seeing various people who delayed enrollment into Medicare for various reasons,” says Frederic Riccardi, director of programs and outreach at the Medicare Rights Center, a nonprofit group that helps people with Medicare disputes.

Part of the problem is due to the absence of what most Americans used to see as a simple dividing line: On or about their 65th birthdays, they were expected to stop working, become eligible for full Social Security benefits and sign up for Medicare. Now that a growing number of people work past 65, and the age threshold for collecting full Social Security benefits is 66 and climbing, the transition period is less clear.

To avoid mistakes, here are five tips to help you navigate Medicare.

–You must sign up for Medicare when you turn 65.

The only exceptions are for people already receiving Social Security benefits — in which case you’ll be automatically enrolled — or are employed (or whose spouse is) and getting health insurance through work. There is a caveat, though, if you are still getting employer-coverage: If you (or your spouse) are working for a firm that has fewer than 20 employees, you must sign up for Medicare because, under insurance rules, Medicare is considered the primary insurer for seniors working at these small businesses.

“We will not be knocking on people’s doors to come in to file,” says Steve Richardson, deputy regional communications director for the Social Security’s office in Boston.

You can start signing up — online, via a toll-free telephone number or in person at a local Social Security office (make an appointment first) — three months before your 65th birthday. You have an additional three months after your birthday month to apply before penalties kick in.

If you hold off because you (or your spouse) are employed and covered by a company plan, you have eight months to enroll after the employment ceases.

And remember, Medicare isn’t family coverage, like you might have had from work. You may be eligible, but that doesn’t cover your spouse or dependent children. They will need to buy insurance from a private company.

— Medicare is not free.

With all the talk about the high federal budget costs of Medicare, some may erroneously think the government pays for all Medicare services. Far from it. Beneficiaries have to pay monthly premiums, deductibles and co-payments or coinsurance. Figuring out your coverage and costs can be challenging, especially given Medicare’s different alphabetic parts: A (for inpatient hospital care), B (for outpatient services and doctor visits) and D (an optional drug benefit). There’s also a Part C, usually known as Medicare Advantage. This is an alternative to traditional Medicare and is offered by private insurance companies.

“Make sure to choose wisely,” advises Riccardi. For example, if you opt for a Medicare Advantage plan, you may get benefits not offered in traditional Medicare — such as eyeglasses — but the plans may restrict doctors or hospitals and require advance permission for certain services. Some Medicare Advantage plans may also limit coverage geographically, so you may be forced to pay out-of-network fees if you visit grandchildren in another state or if you spend the winter in Florida.

Private insurers also offer Medigap policies that supplement parts A, B and D and help cover deductibles, coinsurance costs and services that may be exempt from Medicare coverage. Military retirees can choose supplemental plans from Tricare.

— Medicare does not cover everything, but it may cover a lot more than you think.

“A good rule of thumb is ‘Medicare doesn’t cover most things above the neck,’ ” says Helen Mulligan, a health insurance specialist in Medicare’s Boston office. For example, Medicare doesn’t cover hearing aids, dentures (or most dental procedures) or eyeglasses, although it does cover cataract surgery.

Basic Medicare also doesn’t cover extended stays in nursing homes or treatment overseas, although some of the more expensive Medigap plans do cover overseas travel.

But the 2010 health-care overhaul law made a number of preventive care services free for beneficiaries, including annual mammograms, flu shots and periodic colonoscopies, as well as screening tests for cervical cancer, prostate cancer and high cholesterol. Also covered is an annual wellness visit.

— If Medicare rejects a claim, appeal.

According to some estimates, one in seven claims filed with Medicare are rejected. The reason can be as simple as insufficient or inaccurate information filed by a doctor; often, it’s just an erroneous procedure code that can be quickly corrected.

“It doesn’t hurt to appeal, and it doesn’t cost anything,” says Mulligan. “You don’t need to hire a professional.” Instructions and forms are easy to find and use on the  Web site. (Scroll down to the “Need help?” box and click on “Appeal a claim.”)

But, Riccardi adds, you should not hesitate to enlist the help of your doctor or medical facility, especially if they need to write a letter to explain the medical necessity of a treatment or particular drug.

— Medicare is not just for seniors.

If you have been getting disability benefits from Social Security for 24 months, you can receive Medicare at any age. Medicare also has no age requirements for people with Lou Gehrig’s disease or kidney failure.

This article was updated 12/8/2011 to add information about seniors working at businesses of fewer than 20 people.

This <a target="_blank" href="/aging/baby-boomer-medicare/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

“She had the best of care for five months,” says Turner, a District resident. “A hospice licensed practical nurse came first thing in the morning to help change complex dressings, a primary nurse visited several times a week, there was an on-call nurse to help address pain-control questions in the middle of the night, plus a social worker and a chaplain. It took all of us to get through those weeks.”

Still, Turner tells families, she had to bear much of the caregiving, even taking a leave of absence from her job. “I treasured that time, but it was physically and emotionally exhausting. Hospice made it doable, but the truth is, it was still a lot of hard work.”

Some families, she says, may not be able to bear that burden, certainly not without hiring extra help. But, she says, “the hospice gave me the skills and confidence to do what I wanted so badly to do for my mother. I will always be grateful.”

Introduced to the United States in the 1970s, hospice care is becoming an increasingly common treatment. Last year, 1.65 million people received hospice care, up from just more than 1 million in 2004, according to the National Hospice and Palliative Care Organization. In addition, there were more than 5,500 programs in the U.S. last year, compared to 3,100 in 2000.

Although the growth in hospice programs has given patients and their families more choices than ever, a recent into the industry found widespread concerns about the quality of care. The Post cited numerous complaints, noting that although hospices are supposed to provide continuous nursing care to patients whose pain or symptoms are out of control — commonly called “crisis care” — one in seven do not.

Unfortunately, there is no federal rating system — as there is for hospitals and nursing homes — that can help consumers make educated choices about the hospice they select.

For many families, hospice is an unfamiliar concept that prompts fear and questions, including where, why and even when someone should receive hospice care. To help patients and their caregivers, here are some hospice basics:

What Is Hospice Care?

Hospice is not a particular place, like a hospital, but a service that provides end-of-life care and support to the dying and their families, most often in a patient’s home. By signing up for hospice, patients generally agree to stop all disease-fighting treatments, such as chemotherapy and radiation, although some hospices allow such therapy if it is to help manage symptoms, such as pain or problems breathing.

One of the hospice’s primary goals is to alleviate pain. Through a team of caregivers — doctors, nurses, social workers, grief counselors, spiritual counselors, home health aides and volunteers — the hospice provides comprehensive care, including drugs, medical supplies and equipment. It instructs families on patient care and even provides special services such as physical therapy and psychological counseling.

“If we can manage and alleviate pain, we can help reinvigorate patients to help them accomplish whatever it is they want to do in their remaining days, whether it’s making peace with an estranged sibling, attending the wedding of their grandchild — or just going out to eat or fish,” says Malene Davis, president of Capital Caring, one of the first hospices in the Washington area. It now cares for about 1,200 patients a day.

How Much Care Does Hospice Provide?

Comprehensive care generally does not mean around-the-clock service, although many hospices provide 24/7 care when the patient is in crisis or near death.

“The hospice will teach families how to care for a patient, address their concerns and answer questions, but it does not take over the caregiving,” says Dale Lupu, an associate professor at George Washington University’s Center for Aging, Health & Humanities. “Someone on the hospice staff should be available by phone 24/7 in case there’s a crisis. But for hour-by-hour, day-to-day care, the family has to figure out a way to be involved,” even if it means hiring a private nurse or home health aide.

That’s one reason why hospice care may not be for everyone. “Families have to look within themselves and ask if they are comfortable being part of the dying process,” says Linda Kunkel, director of marketing and business development for Care Options, a Northern Virginia care-management firm. “It can be very gut-wrenching and, for some people, very hard.”

Who Pays For Hospice Care?

Medicare covers most hospices for its beneficiaries. Private insurance plans and HMOs also generally pay for hospice care, but they may have a preferred provider. Check with your insurer before you begin your hospice search.

In some cases, a small co-pay — such as $5 or 5 percent — may be required for medication, inpatient facility care and/or respite care.

Additionally, most hospices offer financial help for families in need. So make sure to discuss any financial concerns in your initial meetings.

If Hospice Is Not A Place, Where Do I Get Hospice Care?

Nearly two-thirds of hospice patients die at their homes, a nursing home or an assisted-living facility.

For patients who can’t be cared for at home — perhaps they live alone or have complications that can be treated only at a health-care facility — some hospices have inpatient facilities in freestanding centers or specially designated sections in hospitals or nursing homes.

Why Would I Want Hospice Care? Can’t My Doctors And Local Hospital Adequately Meet My Needs?

Surprisingly no, hospice experts say.

“The traditional medical approach is cure, cure, cure; but when a person is dying, he or she may need a different approach,” says Linda Adler, head of Pathfinders Medical, a California health-care advocacy firm that helps patients with complicated medical diagnoses. “The patient needs someone who’s willing to move the conversation from finding a cure to having best quality of life in the midst of an illness, someone who’s not afraid to talk about the end of life and provide compassion in the final days. Most physicians aren’t trained to do that.”

Hospice caregivers also have in-depth training and experience in palliative treatments for pain management. “Most doctors are not adequately trained in pain management, and the quality of pain control in hospitals and nursing homes is very uneven,” says Naomi Naierman, who was the president of the American Hospice Foundation before it closed last year.

When Should I Start To Think About Hospice?

Most hospices require an order from the patient’s physician as well as approval from the hospice medical director. Both must certify that the patient has six months or less to live if the illness runs its normal course. However, if a patient outlives that time, he or she can be “recertified” to continue receiving hospice care.

But experts in end-of-life care say most Americans need to start thinking about hospice long before the final six months is near. As the American Cancer Society notes on its website: “One of the problems with hospice is that it’s often not started soon enough. Sometimes, the doctor, patient, or family member will resist hospice because he or she thinks it means you’re ‘giving up,’ or that there’s no hope. This is not true. If you get better or the cancer goes into remission, you can leave hospice and go into active cancer treatment.”

Indeed, hospice experts say many people leave hospice, a situation that the late humorist Art Buchwald made famous when recounting his own discharge from a hospice. Patients can then be readmitted to hospice when their conditions deteriorate again.

J. Donald Schumacher, president of the National Hospice and Palliative Care Organization, says patients should discuss hospice options as early as they are diagnosed with a potentially fatal disease. “Don’t wait for the doctor to begin the conversation. Even if you agree to aggressive therapy, ask what are the plans if you don’t return to your optimum health.”

Are All Hospices The Same?

No; they vary greatly.

An increasing number of hospice organizations are for-profit, a distinct change from the early days of the hospice movement when they were mostly nonprofit. Today, 65 percent of hospice organizations are operated as for-profit companies, up from 34 percent in 2000.

Being a for-profit company is not inherently bad, but many of the complaints about substandard service have been leveled at for-profit hospice firms, The Post investigation found. The Post reported that the typical for-profit spent less on nursing and was less likely to have sent a nurse in a patient’s last days of life.

Still, Adler of Pathfinders Medical says consumers shouldn’t necessarily refuse to use a for-profit concern. “There are bad hospices, just like there are bad doctors” in both for-profit and nonprofit organizations, she says. “There are also great hospices in both kinds of groups. That’s why people need to do their homework.”

How Do I Find A Good Hospice?

First, seek recommendations from health-care providers and specialists such as geriatric-care managers. Ask which hospice they would use for themselves or a loved one.

Next, call the recommended hospices and ask questions about the issues that matter most to you, such as:

— How often do their caregivers come to visit? (A nurse’s aide should visit about three times a week and a nurse or doctor once a week, Naierman says.)

— Are their doctors and nurses certified in palliative care?

— Is there crisis care? How fast can a caregiver get to your home in case of a crisis? Will they come at any time, even 3 a.m. Saturday?

— Will the patient’s primary doctor still be involved in the medical care?

— Will a nurse or clinician be in the home when the patient is actively dying? (“The answer should be yes,” Naierman says. “If it is anything but yes, run, don’t walk, away.”)

— Is there an inpatient facility if the patient needs extra care? Is it conveniently located?

— Are there limits on radiation and chemotherapy, even if it’s to control pain? What about IVs, dialysis or blood transfusions?

— How does the hospice handle new health problems that are curable, such as urinary tract infections or pneumonia?

— What is expected from family members? What will they be required to do? Give medicine, including shots? Bathe the patient?

— Is respite care – providing relief and time off for caregivers – offered?

“Having a conversation with the hospice admission people helps you get a feel in advance on how receptive they will be to your needs,” says Naierman, who helped develop to ask a hospice.

Are There Any Other Criteria To Judge The Quality Of A Hospice?

Yes. Here are some details to look for:

— Accreditation status. Three organizations — the Joint Commission, the Accreditation Commission for Health Care and the Community Health Accreditation Program — inspect and approve hospice programs.

“I would always lean toward an accredited program when available because it speaks to a program’s willingness to open itself to review and, hopefully, improvement,” says Lupu, who notes that only 40 percent of hospices are accredited.

— Age and patient load. “Experience — gained over time and gained over a number of cases — usually helps build both individual clinician expertise and organizational/team expertise,” Lupu wrote in a , a blog about hospice and palliative medicine. “Very new and very small hospices are unlikely to have the breadth of experience and the depth of resources to assist with challenging or unusual circumstances.” She suggested that patients should generally lean toward an organization with at least five to 10 years of experience that handles at least 80 patients a day.

— “Live discharge rates,” which is the proportion of people who leave hospice care before dying. A large number of departures may signal that patients were unhappy with care and services. “I’d select a hospice with a live discharge rates in the 10 to 20 percent range,” Lupu says.

Where Can I Go For Additional Help?

There is a lot of information on hospices on the Internet, including:

— The website and its page.

— The American Hospice Foundation’s educational .

— The on hospice care.

— The Washington Post’s .

This article was produced by Kaiser Health News with support from .

This <a target="_blank" href="/aging/learning-about-hospice-should-begin-long-before-you-are-sick/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This KHN story was produced in collaboration with

Call it a wonky version of “American Idol” — or, perhaps more aptly, “Research for a Cause.” Four Georgetown University Medical Center scientists recently delivered 15-minute sales pitches about their work, hoping to win money from an unusual panel of judges: local residents who are not experts on science.

The first scientist showed cartoonlike drawings to explain how osteoporosis occurs. The second aired a video of a kidney transplant. The third projected a CT-scan image of the brain of a U.S. soldier severely injured in Iraq. The fourth displayed a photo of a tumor-ridden liver, a picture so graphic that she warned her audience that some might want to avert their eyes.

To become a judge, each individual agreed to donate at least $1,000 to the medical center. In return, the donor received a chance to review a handful of proposals by Georgetown researchers and vote for a top choice. The two projects garnering the most support each got a grant of $35,000. Donors also receive periodic progress reports on the studies and a tour of the labs.

The program, called Partners in Research, was launched by Georgetown in 2011 as part of an effort to develop new ways to finance biomedical research.

“Without a great track record or good preliminary data, it’s increasingly hard to win funding” from the National Institutes of Health or private foundations, says Vivien Marion, a senior director in the medical center’s office of advancement. In fact, the odds of winning an NIH grant have been steadily decreasing; in the past two years, less than 20 percent of applications have received funding, down from 30 percent 10 years ago as NIH’s budget for research grants has been flat while the number of applications has increased.

Partners in Research was designed to provide just enough funds to innovative projects to generate data that could “put researchers on a path to win more money” from other sources, says Marion, who runs the program and has contributed $1,000 to it each year.

This year, 59 partners donated $70,000; they selected their top funding choices last month.

This year’s winners were a project that explores new strategies to prevent osteoporosis and one that examines whether a drug used to treat hypertension and diabetes can reduce damage caused by traumatic brain injuries. The runners-up: a proposal to evaluate a new technology that might help doctors determine if donor kidneys are healthy enough for a transplantation and a study to find new molecules in the lab that could block a protein associated with cancerous tumor growth.

“You feel bad that you can’t support them all,” said Bette Kramer, who hosted a wine-and-cheese party to recruit donors.

“I give to a lot of different causes,” said Kramer, a retired District resident. “But this is personally gratifying because it’s an exciting way to participate in what’s going on in science and medicine today. I view this like venture capital, as an opportunity to provide funds for scientists looking for a breakthrough.”

The partners program reflects a growing trend of raising funds through “crowdsourcing,” in which individuals pool multiple small donations for greater impact. Internet sites such as Kickstarter, for example, have raised money from a large number of participants to fund projects proposed by various start-ups and researchers. Other Web sites, including GiveForward.com, GoFundMe.com and YouCaring.com, have allowed patients to solicit money to help underwrite their medical costs.
For people who prefer personal contact with fellow donors, there are giving circles, where individuals meet to select charities to receive their pooled donations.

Partners in Research grew out of a Georgetown promotional campaign designed to generate donations. In 2009, the university launched Doctors Speak Out, a community education program that hosts discussions of health issues. At these quarterly luncheons, university scientists detail how their research touched on these issues.

Donations were not required, but they were not discouraged, either. Many attendees would make contributions, often designating the funds for two research on one of the topics discussed. “The money was so diluted, it didn’t make enough of a difference,” Marion says. Trying to create a bigger impact, she thought of the growing popularity of giving circles and hoped a similar concept could work for Georgetown’s biomedical research projects.

Support has remained steady. The first year, 63 partners raised $75,000, which was split among three projects. In 2012, 62 partners who raised $70,000, which was shared by two projects.

For researchers, it’s a competitive process just to win a spot on the presentation platform, with each proposal undergoing a peer review by other Georgetown researchers. The first year, a dozen projects were reviewed and five finalists selected. Last year, there were nine applications and four finalists. This year, 34 applications were winnowed down to a final four that went before the judges.

Still, the process is easier than seeking other funds. “There’s less red tape, and if you’ve got a new, innovative idea but no pilot data to support it, this program gives you an opportunity to start building data to support outside funding in the future,” said Adam E. Green, an assistant professor of psychology whose team won one of the first year’s awards, for research into Alzheimer’s disease. Now his group is writing applications for outside funding. “I’m not sure how else we would have gotten to this point,” he said.

Mark Burns is one of this year’s winners, for his work on brain trauma. “This first step is an important one that will allow us to test our principal hypothesis and enable us to generate the exhaustive preliminary data that is required to secure a large research grant,” said Burns, an assistant professor of neuroscience.

Similarly, the grant enables scientists to follow their research into areas not initially expected. Rebecca Riggins, an assistant oncology professor, said she was able to expand her study of a promising breast cancer drug when tests showed it was also effective at killing brain tumor cells. Without the Partners in Research  grant last year, Riggins said, “I’m not sure we would have been able to pursue the brain tumor research; all that work would have been an orphan.”

None of the researchers has obtained outside finding yet, but they are working toward it.

Researchers acknowledge that the competition before the judges might turn into a popularity contest, with those that have the most dynamic and/or sympathetic presentation winning the funds. But, Robert Clarke, dean for research at the medical center, said, “It really doesn’t matter. It’s all good science, so not a penny will be wasted.”

The winners cite an additional benefit: personal engagement with the donors. Says Nady Golestaneh, director of research in the ophthalmology department, says, “The money is very useful, nice, but the personal donor support makes us even more motivated in our research.”

This <a target="_blank" href="/news/american-idol-style-grant-funding/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This <a target="_blank" href="/aging/long-term-care-insurance-tips-sidebar/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This story was produced in collaboration with

In the last years of Martin Privot’s life, his family had to start selling his assets to pay for his nursing home costs. “He needed 24-hour care and couldn’t be left alone,” recalls his daughter Toni Footer. “My biggest fear was we would run [through his money] and wouldn’t be able to provide the care that he needed.”

Toni Footer with a photo of her late father, Martin Privot. She says his experience “reinforced my already strong feelings that long-term-care [insurance] is a necessity” (Bill O’Leary/The Washington Post).

Privot died in 2008, from post-surgical complications and other ailments, before all his assets were depleted. Yet Footer, 61, says her dad’s experience “reinforced my already strong feelings that long-term-care [insurance] is a necessity.” The Rockville, Md., resident says she pays about $2,500 every year for such coverage for herself. “It’s expensive — in fact, it’s gone up twice — but it’s worth every penny. It provides a peace of mind that my family won’t have to struggle to find money to pay for my care.”

Mary McClelland came to the opposite conclusion after seeing how her mother’s expenses were often deemed exempt from coverage.

Her mother, Ruth Mezick, purchased long-term-care, or LTC, insurance in 1990 at age 78 when she was in fairly good health, paying an annual premium of $2,827 until she died 11 years later. In her mid-80s, her health began to deteriorate, and she spent time in a nursing home, at home with help and in assisted living. But her policy — which promised to pay $100 a day — failed to cover much of those expenses because it kicked in only after she had been in one institution more than 100 days.

“She was never in one place long enough to qualify. She ended up getting about 10 days’ coverage, worth about $1,000,” says McClelland, who lives in Falls Church, Va. “That was a lesson to me; I decided it doesn’t always pay off.”

Mary McClelland found that many of her mother’s expenses were not covered by her long-term-care insurance plan (Bill O’Leary/The Washington Post).

The question of whether to get long-term care insurance bedevils consumers and their advisers. Unlike medical insurance, it is intended primarily to cover people who need assistance with so-called activities of daily living — for example, the care of a dementia patient or someone recovering from a broken hip. It can be expensive: Premiums range from $1,000 to $5,000 a year, depending on the age, sex and health of the purchaser as well as the extent of the coverage. And policy details can be confusing.

Even advocates acknowledge that it isn’t for everyone. Jesse Slome, executive director of the American Association for Long-Term Care Insurance, an industry group, sums it up well: “Long-term care is a universal issue facing all Americans who are getting older. But long-term-care insurance is not a universal solution.”

So how great is the need for such coverage? It depends on how you look at the data. “One in two Americans are likely to need long-term-care services sometime in their lives,” says Amy Pahl, a consulting actuary for Milliman Inc., a leading actuarial and consulting company. However, Pahl adds, of those who might need long-term care, about a third will not meet the most common deductible period of 90 days because they will either die or recover before then.

To determine if a long-term-care policy makes sense for you, it is important to understand how the coverage works and what’s available.

Don’t Think Medicare Will Cover You

Most standard health insurance plans do not cover long-term care. Nor does Medicare or insurance policies that supplement Medicare.

Medicaid, however, is the largest source of coverage for long-term care. The program pays for more than two-thirds of nursing home residents, according to  from the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

But Medicaid comes with significant limitations. The choice of facilities that accept Medicaid is narrow, and the program is restricted to people with extremely limited income and virtually no resources, which forces middle-income consumers to spend down their assets if they want to qualify.

“Medicaid is supposed to be a safety net, but unfortunately it rests just about a half-inch off the floor,” says Tom West, a Northern Virginia financial adviser and long-term-care expert.

Yet Kansas Insurance Commissioner Sandy Praeger cautions that long-term care policies may not be a good investment for some people. “It’s mostly a policy to protect your assets [so you don’t have to sell everything to pay for care] in case you get sick. If you don’t have assets to protect, then you shouldn’t be buying it.” But even those with few assets might consider some protection because it will allow them more flexibility than Medicaid if they need to choose a nursing home.

How The Coverage Works

Typically, a policy pays a fixed daily benefit ($150 is common) for a certain period of time (often three to five years) starting at a specified time (90 days is common) after the beneficiary becomes disabled. The policy covers nursing home expenses, assisted living charges or less costly in-home-care bills.

Many policies also allow the initial fixed daily benefit to rise 3 or 5 percent annually to keep up with health-care costs. The policyholder agrees to a premium that can increase only if the change is approved by state regulators. Such increases have occurred frequently in recent years and, as a result, once-flat premiums have risen sharply. So have nursing home costs, which averaged about $214 a day — or more than $78,000 annually — for a semi-private room last year, according to a national  by the insurer MetLife.

“Long-term care insurance keeps you from being dependent on the government or relatives and it provides liquidity, even for people who have a lot of assets,” says Rockville financial planner Arthur Stein. “You don’t have to rush and sell assets in a down market, like today’s, to cover health costs.”

As people’s needs have changed, long-term care policies have expanded to cover assisted living and home care; some new policies are flexible enough to anticipate technologies that don’t yet exist, such as robotic care.

“The policies have become very innovative,” says Slome. “Today you can go in and design coverage for particular needs and desires; you can even buy long-term-care insurance to enable you to get your care on a cruise line if you want it — and can afford it.”

Today’s policies can also allow couples to share benefits, so a husband and wife can each buy a shorter-term policy, for example three years of benefits. About 70 percent of coverage today is sold to couples, Slome said. If it turns out that the husband needs more than three years’ coverage, he can tap into his wife’s benefit pool. And in some policies, if the husband completely exhausts the couple’s coverage, the wife may still receive some nominal benefits if she needs care, too.

At the end of 2010, about 7 million Americans had long-term care insurance, according to LIMRA, an association of life insurance and financial service companies. About 422,000 new policies were written in 2010. About 56 percent were sold individually, with the rest sold through employer- or association-sponsored sales.

The 2010 health-care law has a provision creating a voluntary, long-term care insurance program. However, in October, the Obama administration announced it would not implement the provision (called the CLASS Act) because it was financially unsustainable.

According to Slome, the average age of the buyer is 57, with three-quarters of the policies written when purchasers are between 45 and 64.

When buying insurance, the younger the consumer, the lower the annual premiums. Today, according to Slome’s association, a 55-year-old couple in generally good health can expect to pay $2,675 a year for $338,000 of benefits; that figure would grow to $800,000 by the time they reach 80 if the policy contained a 3 percent annual compounded escalation clause. If they are 65, however, that same policy would cost $4,660 a year and grow to only $527,000 in coverage when they are 80.

For Washington area residents, even that coverage can be less than needed. , a comprehensive listing of retirement community, nursing home, assisted living and rehab facilities and home-care options in the area, puts the daily local cost per person of nursing home care at $235 to $304, or nearly $86,000 to $110,000 a year. Daily assisted living costs run between $108 and $162. (The SourceBook is owned by The Washington Post Co.)

Steep Rate Increases

One of the key concerns among consumers is the rise of premiums.

“It’s probably the most frequent complaint I hear,” says Praeger, who heads the National Association of Insurance Commissioners’ health and managed care committee. “The problem is, the older policies weren’t priced right to begin with. Companies expected about 8 percent of customers to stop paying their premiums, when, in fact the lapse rate is closer to 2 percent.” That meant the insurers had to cover more beneficiaries than they expected at a time when the economic downturn has meant less return
on their investments.

Praeger acknowledges that rate increase requests have posed a dilemma for insurance commissioners. “If we don’t give them the rate increase they need, the insurance carriers could become financially impaired, and that doesn’t help people,” she says. In fact, in recent years, a number of companies have stopped selling policies. As a result, she adds, it’s hard to turn the increases down.

The policies can be very complicated, and Praeger advises consumers to consult with their accountant, attorney or other trusted financial adviser before purchasing a policy. “It’s important  to understand what you’re buying, what the benefits are. It’s very complicated so work with someone you know and trust if you want to buy a policy.”

This article was produced by Kaiser Health News with support from .

This <a target="_blank" href="/aging/calculating-a-long-term-care-policy/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

(Illustration by James Fryer for The Washington Post)

?

Throughout Robert Joseph’s career, the Alvin, Texas, electrician always understood his health insurance policies. “I’ve never had a problem,” Joseph says, “until I tried to sign up for Medicare.”

The chief reason: Joseph didn’t sign up when he turned 65. He was still working, receiving health insurance from his employer. And when his company went bankrupt at the end of 2009 — Joseph was then 67 — he received 18 months of severance pay.

“On my last day of work, I went to the Social Security office, asking for some guidance,” recalls Joseph. He never spoke to an expert; instead, he says, he was handed a couple of forms to complete. He researched his Medicare handbook, which noted that “current” employees didn’t need to apply for Medicare. Since he continued to get monthly severance checks that deducted Medicare taxes and he was allowed to continue buying health insurance through the same carrier for the 18 months, he thought he could wait to join Medicare. He was wrong.

Medicare no longer considered him a “current” employee and said he should have enrolled within eight months of his layoff, not 18 months later. As a result, for the rest of his life, Joseph may have to pay extra on his monthly Medicare premium (10 percent for each year he delayed enrollment after his job ended). Even worse, Joseph will be without any insurance for a year. Under Medicare rules, he has to wait until the next open enrollment period, beginning in January, to sign up, and coverage won’t begin until July.

Joseph is not alone. “We’re seeing various people who delayed enrollment into Medicare for various reasons,” says Frederic Riccardi, director of programs and outreach at the Medicare Rights Center, a nonprofit group that helps people with Medicare disputes.

Part of the problem is due to the absence of what most Americans used to see as a simple dividing line: On or about their 65th birthdays, they were expected to stop working, become eligible for full Social Security benefits and sign up for Medicare. Now that a growing number of people work past 65, and the age threshold for collecting full Social Security benefits is 66 and climbing, the transition period is less clear.

To avoid mistakes, here are five tips to help you navigate Medicare.

–You must sign up for Medicare when you turn 65.

The only exceptions are for people already receiving Social Security benefits — in which case you’ll be automatically enrolled — or are employed (or whose spouse is) and getting health insurance through work. There is a caveat, though, if you are still getting employer-coverage: If you (or your spouse) are working for a firm that has fewer than 20 employees, you must sign up for Medicare because, under insurance rules, Medicare is considered the primary insurer for seniors working at these small businesses.

“We will not be knocking on people’s doors to come in to file,” says Steve Richardson, deputy regional communications director for the Social Security’s office in Boston.

You can start signing up — online, via a toll-free telephone number or in person at a local Social Security office (make an appointment first) — three months before your 65th birthday. You have an additional three months after your birthday month to apply before penalties kick in.

If you hold off because you (or your spouse) are employed and covered by a company plan, you have eight months to enroll after the employment ceases.

And remember, Medicare isn’t family coverage, like you might have had from work. You may be eligible, but that doesn’t cover your spouse or dependent children. They will need to buy insurance from a private company.

— Medicare is not free.

With all the talk about the high federal budget costs of Medicare, some may erroneously think the government pays for all Medicare services. Far from it. Beneficiaries have to pay monthly premiums, deductibles and co-payments or coinsurance. Figuring out your coverage and costs can be challenging, especially given Medicare’s different alphabetic parts: A (for inpatient hospital care), B (for outpatient services and doctor visits) and D (an optional drug benefit). There’s also a Part C, usually known as Medicare Advantage. This is an alternative to traditional Medicare and is offered by private insurance companies.

“Make sure to choose wisely,” advises Riccardi. For example, if you opt for a Medicare Advantage plan, you may get benefits not offered in traditional Medicare — such as eyeglasses — but the plans may restrict doctors or hospitals and require advance permission for certain services. Some Medicare Advantage plans may also limit coverage geographically, so you may be forced to pay out-of-network fees if you visit grandchildren in another state or if you spend the winter in Florida.

Private insurers also offer Medigap policies that supplement parts A, B and D and help cover deductibles, coinsurance costs and services that may be exempt from Medicare coverage. Military retirees can choose supplemental plans from Tricare.

— Medicare does not cover everything, but it may cover a lot more than you think.

“A good rule of thumb is ‘Medicare doesn’t cover most things above the neck,’ ” says Helen Mulligan, a health insurance specialist in Medicare’s Boston office. For example, Medicare doesn’t cover hearing aids, dentures (or most dental procedures) or eyeglasses, although it does cover cataract surgery.

Basic Medicare also doesn’t cover extended stays in nursing homes or treatment overseas, although some of the more expensive Medigap plans do cover overseas travel.

But the 2010 health-care overhaul law made a number of preventive care services free for beneficiaries, including annual mammograms, flu shots and periodic colonoscopies, as well as screening tests for cervical cancer, prostate cancer and high cholesterol. Also covered is an annual wellness visit.

— If Medicare rejects a claim, appeal.

According to some estimates, one in seven claims filed with Medicare are rejected. The reason can be as simple as insufficient or inaccurate information filed by a doctor; often, it’s just an erroneous procedure code that can be quickly corrected.

“It doesn’t hurt to appeal, and it doesn’t cost anything,” says Mulligan. “You don’t need to hire a professional.” Instructions and forms are easy to find and use on the  Web site. (Scroll down to the “Need help?” box and click on “Appeal a claim.”)

But, Riccardi adds, you should not hesitate to enlist the help of your doctor or medical facility, especially if they need to write a letter to explain the medical necessity of a treatment or particular drug.

— Medicare is not just for seniors.

If you have been getting disability benefits from Social Security for 24 months, you can receive Medicare at any age. Medicare also has no age requirements for people with Lou Gehrig’s disease or kidney failure.

This article was updated 12/8/2011 to add information about seniors working at businesses of fewer than 20 people.

This <a target="_blank" href="/aging/baby-boomer-medicare/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">