Nebraska Department of Insurance

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THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM

MARCH 1999 NICA NEWS

ISSUES

Private Contracts with Doctors and Other Practitioners
Who Have Decided Not to Provide Services Through Medicare

A Private Contract is a contract between a Medicare beneficiary and a doctor or other practitioner who has decided not to provide services through the Medicare program (not bill for any service or supplies to Medicare for at least two years).

The Private Contract only applies to the services provided by the doctor who asked you to sign the agreement. You cannot be asked to sign a Private Contract when you are facing an emergency or urgent health situation. If you want to pay on your own for services the Original Medicare Plan doesn't cover, your doctor does not have to leave Medicare or ask you to sign a Private Contract. You are always free to obtain non-covered services on your own if you choose to pay for the service yourself.

Under a Private Contract:

No Medicare payment will be made for the services you receive.
You will have to pay whatever the doctor or practitioner charges you with no limit on the charges for Medicare approved services (the limiting charge will not apply).
Medicare Managed Care Plans will not pay for these services.
No claim should be submitted, and Medicare will not pay if one is.
If you have a Supplemental Insurance (Medigap) Policy, the policy will not pay anything for this service.
Many other insurance plans also will not pay for the service.

In Nebraska, only one doctor has decided to not to provide services through the Medicare program.

Caring for the Caregiver

Caring for an impaired or elderly person can create physical, financial, environmental, and/or emotional stress. Caregivers often experience mixed emotions. Love for a family member and the satisfaction derived from helping may coexist with feelings of resentment and frustration about the loss of privacy. Caregivers must be aware of the stress caused by these conflicting emotions and guard against becoming physically and emotionally drained. The following tips can help caregivers care for themselves, so they can better care for their loved ones.

Acknowledge your feelings. Your feelings have a lot to do with the way you view and cope with caregiving. All feelings are legitimate, including anger, frustration, and sadness. Recognizing and accepting your emotions is the first step toward resolving problems of stress.

Stay healthy. Your general well being is extremely important. Remember to eat balanced meals, exercise, get enough sleep, and allow yourself personal time.

Be informed. Check your library for books, articles, and brochures on caregiving. Some hospitals and adult education programs offer caregiving courses.

Join a caregiver support group. Support groups provide caregivers with a forum to share their feelings in a supportive environment. Caregivers can feel less isolated and create strong bonds of mutual help and friendship.

Get a life of your own. Do what you enjoy. Go to a movie, play a musical instrument, or get together with friends. It may not be easy to schedule these activities, but the rewards for having balance in your life are worth it. Meeting your own needs will satisfy you and give you additional strength to bring to your caregiving tasks.

Use respite care services. Consider having your loved one participate in an adult daycare program where he or she can socialize with peers in a supervised setting. This also gives your carereceiver a necessary break from staying home all the time.

Ask for help. Turn to your family, friends, and neighbors for help. Make a list of things-such as time, skills, space, and money-that family, friends and the carereceiver can contribute. Sit down with these people and work out a plan, deciding what tasks will be performed, by whom, on which days.

Also consider a swap with a friend who has similar caregiver responsibilities. He or she may care for both impaired individuals one day a week in exchange for you providing care on another day.

Caregivers: Who they are and how their roles affect them

Three groups have made independent efforts to portray caregivers and how caregiving affects their lives. The staff of the Family Caregiver Alliance analyzed 30 reports published in social science journals in 1994, the Caregiving Newsletter surveyed its readers in 1995 and 1996, and the Alzheimer's Association commissioned the Yankelovich Polling Organization to survey 500 caregivers in 1996. Following, is a look at their results.

Who are they:

Women account for 70-80 percent of primary caregivers.
Caregivers range in age from teens to people in the 90s, but the most typical caregiver is between ages 50 and 60.
About one-third of caregivers provide care entirely unassisted.
About half of caregivers under age 65 have other employment.
Caregivers spend an average of about 70 hours a week in caregiving.
Caregivers who are employed typically spend about 40 hours a week in caregiving.
Nonemployed caregivers often spend 100 hours a week or more in caregiving.
Half of caregivers live with a person who has Alzheimer's disease.
Two-thirds of caregivers have provided care for more than two years.
About two-thirds of caregivers say that their loved one cannot bathe, dress, or go to the bathroom without assistance.
Seven caregivers out of ten are reluctant to leave their loved ones alone, even for brief periods.

How their roles affect them:

90 percent of caregivers use the words frustrating, draining and painful to describe caregiving.
Half say caregiving causes considerable stress within their families.
Half complain that they do not have enough time for themselves.
Almost six caregivers in ten have contributed financially to the support of a beloved one with Alzheimer's disease.
About 33 percent say caregiving has forced them to reduce their work hours, which has reduced their income.
About 33 percent said that preoccupations with caregiving made them less productive at their jobs.
About 20 percent of caregivers stopped their employment because of the demands of caregiving.
Employee caregivers must take an average of 17 days a year off from work because of the demands of caregiving.

Home Health Care

The Balanced Budget Act of 1997 introduces "post institutional home health services during a home health spell of illness" under Part A. This provision does not reduce your access to the home health benefit and only applies to those enrolled in both Part A and Part B.

If you are enrolled in both Part A and Part B, the first 100 home health visits are financed under Part A if you have at least a 3 day consecutive stay in a hospital. Home health services must be initiated within 14 days of discharge from a 3-day consecutive stay in a hospital or within 14 days of discharge from a subsequent skilled nursing facility in which the individual was provided post-hospital extended care services. If the first home health visit is not initiated within 14 days of discharge, then home health is financed under Part B.

After exhausting the 100 visits under Part A, Part B finances home health services. If you have Part A and Part B and come from the community, or do not have a 3 day consecutive qualifying stay, then all home health is financed under Part B without a visit limit.

A post-institutional home health service during a home health spell of illness does not apply to those enrolled in Part A only or Part B only. Part A finances all home health for those with Part A only without 100 visit limit or institutional threshold criteria. Part B finances all home health for those with Part B only without 100 visit limit or institutional threshold criteria.

CONSUMER TIPS FOR LONG TERM CARE INSURANCE

United Seniors Health Cooperative (SHC) strongly recommends the following when purchasing Long-Term Care Insurance:

Seek expert advice and agent recommendations from independent financial planners, local senior organizations, government-funded agencies and consumer organizations.
Do not buy from an agent who sells door-to door or who uses high-pressure tactics.
Ask to see the Outline of Coverage for the policy. However, do not rely on marketing literature alone.
Compare more than one policy from different companies. Work with an independent agent or broker who represents several insurance carriers.