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Medicare Changes Open Up Insurance Plans That Help Elderly Before Illness

Posted on: Sunday, 4 September 2005, 18:00 CDT

Sep. 2--LARGO -- Joan Lopata wouldn't be considered a hot prospect for most health insurance plans.

The 67-year-old retired librarian said she has had seizures, a brain tumor and a stroke in the past two years. Partly paralyzed, she's in a wheelchair, and remains on chemotherapy from a 1990 bout with breast cancer.

But her case was just the sort of challenge that appeals to Evercare, a subsidiary of UnitedHealth Group, one of the country's largest insurers.

Evercare, which has regional offices in Tampa, provides an array of health and social services for older people to help them stay out of a nursing home, keep an eye on them if they must go to one and sometimes, as in Lopata's case, spring them free.

"I was so elated to get out of there and get my life back," said Lopata, who has returned to her Largo mobile home after a year of institutional care. "I can't tell you how I felt. Being there was like being in a jail."

Until now, the only Medicare beneficiaries who could get Evercare services in the Tampa Bay area were those who could pay for them or were like Lopata: poor enough and sick enough to qualify for state-funded care through Medicaid.

Now Medicare rules have been adjusted to allow Evercare and other companies, including Tampa-based WellCare of Florida Inc., to intervene before beneficiaries become that sick.

For people who qualify for both Medicare and Medicaid -- the so-called "dual eligibles" -- such plans will provide not just all medical and drug benefits, but also care managers to make sure elderly people are living safely, with the family or social supports they need.

Lopata, for example, got sick shortly after moving from Wisconsin and doesn't live near relatives. So her care manager had to take care of a multitude of details to ensure that Lopata could manage on her own.

Various members of the Evercare team prepared for Lopata's homecoming by building a ramp for her wheelchair and making structural changes in the bathroom and bedroom that allowed her to move one-handed. They arranged to have the overgrown bushes trimmed, and provided home nurse visits and transportation for doctor visits.

Now Lopata needs less help. Evercare sends a nurse's assistant to help her with bathing and other activities several days a week and to take her to the mall to practice walking.

"If it weren't for Evercare I wouldn't be home," Lopata said.

A leading consultant on the new Special Needs Plans, John Gorman, said the programs allow insurers to apply Medicare and Medicaid money to tailor services to the individual.

"It represents one-stop shopping,"he said. "It reduces confusion, fragmentation and a lot of the administrative hassle."

As many as 45,000 elderly people in Hillsborough and Pinellas counties may qualify for the new Special Needs Plans. The income guidelines would include about 10 percent of the Medicare population in Pinellas and 19 percent in Hillsborough.

On average nationwide, a low-income elderly person runs up $20,000 in health costs a year, most of it covered by taxpayers. If that person goes into a nursing home, the cost shoots up to nearly $50,000.

Medicare beneficiaries can qualify for enrollment in the new Evercare program, called Evercare DH, right away in one of two categories:

They are already in a nursing home, or are so sick they could qualify to be in one.

Their income and assets are low enough to qualify for state Medicaid assistance.

A third group of beneficiaries -- those who have chronic illnesses -- will qualify as soon as the Medicare program finishes writing guidelines.

Medicare is making coordinated care plans available to the poor, even if they have few health problems, to keep them from getting sick.

"In the senior population, there's a direct correlation," Gorman said. "The poorer you are, the sicker you are."

Gorman said the new plans take advantage of a change in Medicare's payment methods for managed-care. Until recently, the government paid a flat rate each month for each beneficiary, regardless of health.

Now Medicare has launched a different payment system, which adjusts the premium for health, making high- risk patients more attractive financially to health care companies.

The phase-in, to be completed by 2007, but already many companies see a market where none was before.

Gorman said 50 companies nationwide have been approved by federal officials for Special Needs Plans, and another 100 applications are pending.

"These low-income vulnerable populations are becoming very attractive for companies to serve," he said. Special Needs Plans "are exploding like mushrooms."

For information on the Evercare DH Plan, call 1-800-791-9233. For the hearing-disabled, the TTY line is 1-888-685-8480.

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Source: Tampa Tribune

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