Medicare Coverage of Care Management
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Geriatric Care Managers … coordinating services to optimize health and quality of life.
The National Association of Professional Geriatric Care Managers (NAPGCM) is an organization of practitioners whose goal is the advancement of expert assistance to older adults and their families. NAPGCM is committed to maximizing the independence and autonomy of elders and strives to ensure the highest quality and most cost-effective health and human services. Members help older persons and their families cope with the challenges of aging, through education, advocacy, counseling and services delivery.
Medicare Coverage of Care Management
The Medicare program is an important source of health care coverage for older adults and people with disabilities. It must be comprehensive in its scope of coverage and services, affordable, flexible in the array of covered options, and designed to maximize the good health and quality of life for all of its beneficiaries.
Professional geriatric care management is increasingly becoming recognized as a critical tool in health care and service delivery to older adults and people with disabilities. It can help assure their quality of life is maximized and costly hospitalizations are avoided, if properly conceptualized and implemented. While professional geriatric care managers negotiate the maze of services, they also assess the needs of the older adults and develop plans of care, which are implemented and modified as necessary, based upon the professional geriatric care managers’ monitoring of the effectiveness of the plans of care. Cost savings are expected and usually seen because of improved communication among providers, increased efficiency and effectiveness of service delivery, and the reliance on low-tech, community-based service systems, thus avoiding wasteful spending.
I. SERVICE DELIVERY
A. NAPGCM advocates:
- For the development of care plans which incorporate the physical, environmental, psychosocial, cognitive, and family support needs, as well as a risk assessment of the Medicare beneficiary. Legal and financial considerations should be included.
- That care management services be provided by professionals who are certified and comply with all relevant state/professional licensing requirements. Care manager certification should be through one of three certification bodies: The Commission for Case Management Certification, The National Academy of Certified Care Managers, or the National Association of Social Workers.
- That provisions which require care management services to be provided by or through physicians be avoided or eliminated.
- That care managers adhere to standard professional documentation procedures and/or requirements.
B. NAPGCM supports:
- The utilization of a holistic approach to determine which services are most appropriate.
- Benefits with their primary goal the improvement of the care of the beneficiary.
II. OTHER
A. NAPGCM advocates:
- For the inclusion of all recommended services within the care plan developed for the Medicare beneficiary and for the Medicare beneficiary to have the option, at his/her discretion, to purchase any and all such services not covered by the Medicare program, either privately or through other means of payment, without restrictions imposed by Medicare or having to choose between Medicare or other means of payment.
- For any potential co-payments to be covered by the most commonly held Medigap policies.
- For beneficiaries enrolled in Medicare Advantage plans to have the full range of care management benefits available to them. Managed Care plans should clearly differentiate the role of gate-keeper from the role of professional care manager, where the former manages services for the providers and the latter is an independent, nationally certified professional unaffiliated with the health care provider.
B. NAPGCM supports:
- No means testing for a Medicare care management benefit.
Developed and approved by Public Policy Committee, March 2, 2009, Approved by NAPGCM BOD 4.22.09