Traditionally, Medicare hasn’t covered long-term care. And — spoiler alert — it still doesn’t. However, the rise of Medicare Advantage plans has opened a few doors that weren’t open before. While Medicare still doesn’t provide long-term care coverage — patients will have to subscribe to a different type of plan if they want that — it is beginning to provide coverage for certain aspects of long-term care.

So what “aspects” are we talking about?

What is the Difference Between Medicare and Medicare Advantage?

First, let’s dive into the difference between traditional Medicare (often referred to as Original Medicare) and Medicare Advantage. The first thing to understand is that Medicare Advantage, also known as Medicare Part C, is a private insurance plan. It replaces an individual’s Medicare Part A (hospital visits and inpatient care) AND Part B (physician appointments and outpatient care) with a plan from a private insurance provider. This plan must provide the same benefits as the Medicare plan it replaces. However, it also adds a lot of additional benefits not provided under Original Medicare.

What Types of Benefits Does Medicare Advantage Cover?

In addition to the benefits provided by Medicare Parts A and B, Medicare Advantage plans often offer dental, vision, and prescription drug coverage. Recently, insurance providers have expanded the coverage they offer to include benefits like meal delivery, home care services, rides to medical appointments, and home modifications like bathroom grab bars.

The benefits each plan offers varies based on the area it serves. In qualifying areas, Medicare Advantage plans can even cover grocery deliveries and transportation for non-medical needs for those with chronic illnesses. Some providers also offer options for gym memberships and fitness plans.

Are There Additional Costs with Medicare Advantage?

The cost of each Medicare Advantage plan depends on the plan itself. Most people who qualify for Medicare receive Part A benefits for free and pay a small monthly premium for Part B benefits. This is true for Medicare Advantage, as well. Some plans charge a monthly premium, while others do not. It all depends on which provider an individual chooses for their Medicare Advantage plan.

Custodial Care Vs. Skilled Care

Even with all the changes Medicare Advantage is bringing, it’s still limited in the kind of care it will cover in a long-term care environment. To understand what is covered and what isn’t, we must discuss the different types of care.

Medicare, along with most private insurance plans, pay for services that fall under “skilled care.” This includes medical services, rehabilitation, nursing, or medication administration. Medicare Advantage also covers specialized care, including stays in skilled nursing facilities, hospice care, and some home care services.

So what isn’t covered?

“Custodial care,” not typically covered by Medicare Advantage, includes services that are considered help with activities of daily living, or ADLs. These include eating, bathing, dressing, toileting, and other non-medical care. This is the type of care provided by most long-term care and assisted living facilities.

What Does This Mean for My Nursing Home?

Unless you have a contract with a Medicare Advantage insurance provider, Medicare Advantage will not cover most of the services your nursing home provides for long-term care. Stays in skilled nursing facilities and nursing homes are covered up to the first 100 days (though plans require coinsurance beyond 20 days). After that, residents are on their own. The plans should cover prescription medications and any therapies provided by your facility, however.

For nursing homes, the real benefit of Medicare Advantage is the coverage of prescription medications. Under Original Medicare, medications were not covered unless the resident was under a Part A stay. For many residents, that's a game changer.

While Medicare still doesn’t cover long-term care, the recent expansion of benefits under Medicare Advantage indicate that relief is on the way — and options could be opening up in the future.

February 14, 2020, Duluth, Ga – Prime Care Technologies, Inc. announced today via press release the appointment of Debi Damas to its product management team as Senior Director. In her role, she will contribute her post-acute care and regulatory expertise to the development of the company's SaaS services.

For the past 28 years, Damas has served in leadership roles in clinical services and product management for LTPAC organizations looking to increase quality of care, retention, and ROI.

"We are delighted to welcome Debi and her breadth of knowledge of the senior care industry as we weather the course of regulatory change," stated Jim Hoey, President and CEO, Prime Care Technologies. "Her passion for the LTPAC industry coincides with our mission to help these organizations – through technology – solve the issues that keep them up at night."

Damas holds an Associate of Applied Science, Registered Nurse degree from Cuyahoga Community College, a Diploma in Paralegal Studies/Legal Nurse Consultant, and a nano-degree in Data Foundations. She contributes to McKnight's Long-Term Care News and is a frequent speaker at industry conferences for senior care. 

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About Prime Care Technologies

Since 2003, Prime Care Technologies has equipped long-term care providers with flexible hosting, managed services and cloud software that evolve with industry demand, such as managed care optimization and mobile. Based in Atlanta with 175 employees and 200+ healthcare/IT partnerships, its technology-driven solutions are installed in 6,500+ facilities. With deep multi-vendor interoperability expertise, including the integration of 70+ healthcare applications and 3,500+ EDI payers, Prime Care Technologies offers the leading data warehouse and claims clearinghouse in post-acute care. Learn more at www.primecaretech.com – We provide the tech. You provide the care.

Traditionally, additional revenue is a good thing. However, things aren’t always what they seem. Shortly after the Patient Driven Payment Model was implemented, skilled nursing facilities and nursing homes started reporting boosts in reimbursement. But many analysts are urging providers not to get used to the increased payments.

“The illusion of PDPM budget-neutrality is already over,” writes Michael Zimmet, President and CEO of Zimmet Healthcare Services Group. Zimmet contributed his thoughts on the future of skilled nursing for a January 2020 article in Skilled Nursing News. “We should enjoy the largesse while it lasts,” he continues, “but [we should] prepare for the inevitable correction long before 2020’s back-to-school sales are over.”

But why is PDPM leading to payment boosts in the first place? And what does that mean for future reimbursements?

When New Patients Aren’t New Patients

When the Patient Driven Payment Model was rolled out, most skilled nursing facilities and nursing homes saw an immediate boost in reimbursements. This was due to CMS counting all residents of a care community as new admissions, regardless of how long they had been already been there. Understandably, this rate boost won’t be replicated in the future.

Be Prepared for Inevitable Rate Adjustments

It seems that 9 is a magic number. According to Zimmet Healthcare Services Group, nine out of ten skilled nursing facilities saw a reimbursement boost after PDPM went into effect. On average, SNFs saw an increase of 9 percent or more in Medicare reimbursement. Because the model was designed to be revenue-neutral, industry experts expect that reimbursement rates will be recalculated soon.

The failed attempt at revenue-neutrality has many concerned that CMS could claw back reimbursements or adjust future payments to recoup losses. After all, the goal of model was to cut back on what it saw as inappropriate spending on therapy services that may not be needed.

Length of Stay Issues: When More Can Still Be Less

While per-diem rates are on the rise, the average length of stay is on the decline. This effectively erases any potential boost from per-day payment increases. In fact, CMS data shows that fee-for-service days have decreased by over 17 percent since 2010. Covered days per skilled nursing admission have also dropped by just over 7 percent.

As patient care and outcomes improve, lengths of stay are going to naturally decrease. Unfortunately, this also means that reimbursement will, as well.

What You Can Do to Protect Your Community

The best way to optimize your Medicare reimbursements is to check and double-check your data. Make sure that every diagnosis is captured and reported accurately so you don’t leave money on the table. Inaccurate recording can lead to missed Medicare payment opportunities.

PDPM was designed to be revenue-neutral. CMS didn’t plan to spend any more under this model than it did before. But that’s exactly what is happening, and we don’t expect it to keep happening for long.

Access to more timely data drives decisions to improve productivity and quality care across 30 managed care communities

In a press release today, Prime Care Technologies, Inc. announced that Health Dimensions Group (HDG) has adopted the primeVIEW performance dashboard to track key performance indicators across its 30 managed care communities to improve operational productivity and quality care for seniors. Additionally, the organization will use the dashboard to track the overall organization’s corporate and department performance.

The primeVIEW solution pulls data directly from electronic health records and other core information systems to offer a single analytics dashboard for post-acute leaders. One simple login delivers a multi-dimensional view of facility and organizational performance, empowering senior care providers to accelerate decisions and drive productivity using critical benchmarks, rankings and trends.

“HDG is a mission-driven organization dedicated to improving the lives of seniors,” stated Erin Hennessey CEO, Health Dimensions Group. “Through our aligned sense of mission, we are pleased to partner with Prime Care Technologies on primeVIEW to drive results across all aspects of our organization, including care communities, as well as management and consulting services. Access to more timely operational data will help shape our decisions to expand quality services and programs.”

PrimeVIEW is a cloud-based application providing post-acute operators with data-driven insights by combining census, labor, clinical, revenue cycle, patient satisfaction and Five-Star quality ratings into one decision platform.

“With the ability to drill down to the resident level or view at a corporate level, evaluating outcomes like rehospitalization rates by hospital, facility or diagnosis is easy,” noted Jim Hoey, President and CEO, Prime Care Technologies. “The primeVIEW app also syncs resident-level data with associated MDS and UDA reports, resulting in better decision making and risk mitigation strategies for our customers.”

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About Prime Care Technologies
Since 2003, Prime Care Technologies has equipped long-term care providers with flexible hosting, managed services and cloud software that evolve with industry demand. Based in Atlanta with 175 employees and 200+ healthcare/IT partnerships, its technology-driven solutions are installed in 6,500+ facilities. With deep multi-vendor interoperability expertise, including the integration of 70+ healthcare applications and 3,500+ EDI payers, Prime Care Technologies offers the leading data warehouse and claims clearinghouse in post-acute care. Learn more at http://www.primecaretech.com – We provide the tech. You provide the care.

About Health Dimensions Group
Minneapolis-based Health Dimensions Group (HDG) is a leading consulting and management firm, providing services to post-acute, long-term care, and senior living providers as well as hospitals and health systems across the nation. HDG has been serving health care organizations for more than 20 years with a firm commitment to its values of hospitality, stewardship, integrity, respect, and humor.

Long-term care cyber-attacks are on the rise. From single-location facilities to nationwide organizations, the long-term care industry is facing cyber threats like never before.

How can you keep your long-term care organization safe from attacks? The first step is to know what you’re dealing with.

Threat Type #1: Email Phishing Attacks

By far the most common cyber-attack, email phishing is when a hacker attempts to gain protected information (usually passwords) through deceptive means. Often, victims will receive an email from a trustworthy individual or organization insisting that they click a link or fill out a form. As soon as they do, the hacker captures their information and can use it however they wish.

Phishing attacks are dangerous because they rely on human error, not software loopholes or vulnerabilities. The emails often seem credible. For instance, your staff might receive a bulk email from you stating that their passwords have been reset and that they must enter their login information to confirm. They click the link in the email, which takes them to a landing page that looks exactly like software your organization uses. Since it looks legit, they enter their information, and the attackers now have access to your systems.

Staff training and vigilance can reduce the likelihood of a successful phishing attack, but it only takes one slip-up to compromise your security.

Threat Type #2: Ransomware / Malware Attacks

Malware attacks are viruses, worms, Trojan horses, spyware, or any other type of malicious software application that a user downloads to your system. The programs themselves can do anything imaginable to your network. Some malware simply hides or deletes information. Other programs shut out users or make certain applications totally inoperable.

A malware attack becomes a ransomware attack when the hackers offer to reverse the damage they have caused for a monetary payment. Larger organizations have paid ransoms in the millions of dollars just to get their systems back online.

Malware and ransomware attacks are initiated through clicked links or file downloads. Once downloaded, the program attaches itself to different files and gets to work. Email filters and other scanning programs help, but hackers are finding more and more ways to get these files onto your organization’s computers.

Threat Type #3: Social Engineering Attacks

Phishing isn’t the only cyber-attack that relies on human error. Other types of cyber-attacks take a different, yet still personal, approach to stealing information.

Baiting is a type of cyber-attack that promises a desirable good in exchange for a user’s information. For example, a website might offer free music downloads for providing your email login and password.

Pretexting is all about the story. The attacker creates a plausible pretext for requiring the information they ask from you. For instance, they might ask for your full name, social security number, and mother’s maiden name to confirm your identity. In reality, they’re using that information to commit identity theft.

In the end, your best defense against cyber-attacks is education. Talk to your staff about cyber-attacks and make sure they understand what’s really at stake.

Beyond your employees, consider partnering with an IT provider to secure your long-term care organization’s data against cyber-attacks. For instance, Prime Care Technologies offers a highly secure Tier III+ data center as well as a separate disaster recovery center to its clients.

It’s not a question of if you’ll be the victim of a cyber-attack — it’s when. And when it happens, don’t you want to be ready?