Law Office of Srinoi G. Rousseau

1. A phase out of the Medicare Part D “donut hole” or “coverage gap” by 2020
2. The elimination of Part D cost-sharing for full-benefit dual eligible beneficiaries (those eligible for both Medicare and Medi-Cal/Medicaid) receiving home-based and community-based services
3. Increased federal funding for states that provide home-based and community-based services for seniors with Alzheimers rather than only providing care through nursing homes
4. Beginning next year, Medicare coverage without cost for preventive care services, such as colorectal screenings, mammograms and an annual wellness visit and creation of a personalized prevention and assessment plan
5. An estimated 9-year extension of the Medicare Trust Fund beyond the previously-estimated 2017 depletion

Seniors are living longer and healthier, in large part due to prescription medications which sometimes consume a significant portion of the average senior’s budget. Medicare Part D is a prescription drug program, which pays part of the costs of a person’s prescription drugs for a monthly premium, at least until the person reaches the “donut hole”. In the 2010 Medicare Part D plans, the “donut hole” starts when the retail cost of the medications (not what the senior pays) reaches $2,830 and continues until the retail cost of the medication reaches $6,440, which is when the Medicare Part D beneficiary has spent $4,550 in out of pocket costs for their medications. The $4,550 does not include the portion of their prescription expenses paid by the insurance carrier or their monthly premiums. The existence of the “donut hole” creates quite a financial burden for many seniors. Beneficiaries reaching the “donut hole” in 2010 will receive a one-time $250 rebate. Over the next decade the “donut hole” will be phased out until it is eliminated in 2020.

Some of the additional benefits for seniors are an increase in primary care doctors, nurses, and physician assistants to provide better access to care through expanded training opportunities, student loan forgiveness, and bonus payments; increased support for community health centers; community health teams to coordinate patient care; and programs directed to reducing re-admissions to the hospital when patients are discharged.

A version of this article originally appeared in the Bulletin of the Alameda County Bar Association.

Medi-Cal pays for skilled nursing only, and then only when the resource limits are met. Many facilities do not take Medi-Cal at all. Even if the preferred one does participate in the Medi-Cal program, it may expect a period of private pay initially. As for assisted living, private resources must pay. Especially in a dementia situation, this can be quite expensive.

Rather than hope nothing drastic happens, we encourage clients to seek the help of a good placement service or care manager to assist in considering the options. Facilities with empty beds or rooms may be quite willing to negotiate about costs. A needs assessment will start identifying places that may be appropriate, given the resources available and the location preferred. Going with family members to visit those places, and asking questions that the family may not think about, the placement consultant or care manager can make the process much less stressful, and may be able to reduce the monthly cost.

In one recent case, the placement consultant identified three places, visited them with the son and daughter-in-law, negotiated some cost reductions, and helped the transition by suggesting that the new room be set up exactly like the mother’s bedroom at home, down to pictures on the wall and the rug on the floor. The transition went very smoothly, and the family was happy to have a professional member on their team at this critical time. The care is still expensive, but the cost of the consultant was more than justified by the negotiated monthly savings and the stress reduction all around.

In one incident, an employee ordered duplicate ATM cards when an 86-year-old customer reported his card lost. The employee had friends use the duplicates to withdraw $8,000 from the customer’s account. The customer was unaware of the theft until he was notified that his account was overdrawn, which had never happened to him before.

In another, an employee befriended a customer and was writing checks out for her to sign, some of which were for legitimate bills and others of which were payable to the employee.

Larson said an employee at this Bank of America branch in Lafayette befriended her mother [77-year-old Frances Saimons]. “He was more than very nice. He was charming,” Saimons said.

Saimons said he helped her manage her finances. “Always, he always wrote my checks out,” she said. “He would say sign there, and I would sign it.”

The customer did not realize that $28,000 in checks had been made out to the employee until a bank investigator visited her daughter. The employee claimed that the checks were loans, although the victim denied this and the bank has a policy forbidding such a practice.

Family members are often reluctant to interfere in the personal business of an elder, which is understandable. But polite inquiry about their opinion of the bank, whether they find the bank employees helpful and how, might be acceptable. Sometimes the elder will permit a family member review bank statements. The sooner problems are spotted, the more quickly damage can be limited and, hopefully, remedies sought.

Financial elder abuse can be a crime, and banks are mandatory reporters to Adult Protective Services (APS) when they become aware of such behavior. Notify the bank and APS immediately if you suspect abuse. To obtain more information or to report adult or elder abuse call APS at (510) 577-3500 or toll free at (866) 225-5277, 24 hours a day and all referrals are confidential.

Concept One: Medicare or Medi-Cal

Medicare and Medi-Cal, although they sound alike, are very different, and it’s important to understand what each does in the nursing home context. Medicare is what comes with Social Security and is not “means-tested” (explained below). It does not pay for nursing home care unless the condition is one from which a person might recover, and s/he is making progress toward recovery. Very few residents of nursing homes are covered by Medicare, and even then only for brief periods while rehabilitating from conditions such as broken hips and strokes.

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Fanni Green tells her daughter, Danyealah, about moving her mother, Pauline, into an assisted living facility after her health began to fail.

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