Real Health speaks with Ginalisa Monterroso, founder of the Medicare & Medicaid Advisory Group, an organization that helps families and businesses identify eligibility requirements for Medicare and Medicaid as well as secure these health care benefits.
What are the most common misconceptions people have about the Medicare or Medicaid programs?
The biggest misconception about Medicare is that you have to qualify for this federal health care program. But we actually have taxes deducted out of our payroll toward our contribution for Medicare, which is our health insurance. A lot of people don’t understand that we buy into Medicare, so it’s very important that we continue to advocate for this insurance because when some people retire, they won’t be able to take their health insurance from work with them. They would rely solely on Medicare.
One major misconception people have about Medicaid is that they don’t qualify for this program. What people don’t know is that Medicaid has more than 100,000 programs, and they cover very specific services that target different groups of people. For instance, there’s Medicaid for working women who are pregnant or for individuals who are paralyzed. People think that Medicaid is just this one little office, and you either qualify or you’re denied for particular services.
What are some challenges that make completing the paperwork for Medicare and Medicaid so complicated?
The big complication with each program is that there are many different types of Medicare and Medicaid. Basically, Medicare is of two types: Medicare with a private health organization, such as an HMO or PPO, and stand-alone, or original, Medicare that’s administered through the federal government’s public health care system. With this type of Medicare, you can go to any doctor—there are no referrals—and it works nationwide.
As many people know, HMO companies are very strict. They limit people to getting care from a network of doctors and hospitals, and they are the ones that decide whether we are able to get approved for any type of services. We recommend that individuals opt for the Medicare that’s not connected with an HMO. I call it the freedom plan.
Medicaid is also a program that’s overseen by the government, but each state chooses its own way to administer the plan and determine eligibility requirements. For example, there are different types of income requirements, such as how much money you’re allowed to have in the bank. Medicaid also depends on what kind of service you are interested in accessing.
In addition, Medicaid can be a short-term solution for those who need additional health care coverage or assistance with their rent or food. A lot of people don’t take advantage of these services because of pride and ego. But what people don’t understand is that we work for these benefits in the event we have an emergency, and our tax dollars pay for them.
Based on your experience, do you find that most people understand the differences between Medicare and Medicaid?
I’ve found that people do not understand that Medicare and Medicaid are both health insurances that benefit us and that they are resources that we can utilize in an emergency. When we think about Medicaid, the picture that comes into our mind is that we have to be poor or living in the streets, and it becomes an ugly word. But Medicaid can help us whether we need it in the short term or when we get older and we need assistance with long-term care.
It’s the same thing with Medicare. A lot of people don’t understand it’s a health insurance, and they’re unsure of how to navigate all of its different components and benefits. So it’s about making sure that we ask all the questions and do lots of research. We buy into Medicare, and if we utilize it correctly and we know everything about it, we’re able to benefit from the program.
Under Medicaid or Medicare if someone needs to place a parent in a nursing home, what are the most common challenges they would encounter?
Right now, it would be staffing. All the nursing homes that get paid by Medicaid earn only a very small rate. A lot of nursing homes want a profit off that rate, so they don’t staff their facilities appropriately. For example, you may have a floor of 60 nursing home residents but only two nurses on staff. That’s not good. You always want to make sure that when you’re picking a nursing home, the facility is rated with at least five star stars [under the Centers for Medicare & Medicaid Services Five-Star Quality Rating Systems created to provide residents and their families with an easy way to understand assessment of nursing home quality to help them distinguish between high and low performing facilities] because you want to know that there’s enough staff to take care of our elderly loved ones.
What basic advice would you give to folks who need to place a loved one in a nursing home?
First, I would suggest that individuals try to keep their loved one at home. When we’re dealing with someone who’s elderly and needs assistance, the first instinct may be that we need to put them into a nursing home. But the biggest fear many older people have is that someone is going to put them in a nursing home. Nobody wants to be removed from their home and put in a place where they’ll live in a community environment with no privacy and where they may pass away.
Always speak to your elderly loved ones. Ask them what their wishes are. Keep them involved in making this decision. A lot of family members, especially children, think that they have to make sure that their mother or father is in a nursing home and they’re being cared for because it’s the right thing to do. Often, what happens is that loved ones are admitted into a nursing home and they decline; they become depressed and pass away.
Right now, the federal government has many programs in place to ensure that older people are able to stay home and live in an environment that’s familiar to them.
What funded services does Medicare have in place that would allow people to keep their loved ones at home?
Medicare actually has a free home care component. The program will pay for up to four hours of home care each day. And if someone would benefit from this type of care and some additional rehab, such as physical therapy, speech therapy or occupational therapy, all someone has to do is go to their loved one’s primary doctor and request that he or she write a referral for Medicare home care services; that’s free.
In your opinion, what would make it easier for people to receive Medicare and Medicaid benefits for all kinds of health-related care?
In one word: planning. Make sure that if you have a financial adviser you’re speaking to that person and saying that, eventually, you want to start saving to make sure you have money for your long-term care. We plan for a wedding, baby shower or a cruise, but we don’t plan for us growing old. That’s something that we always should do very early on because we all are going to get older. We all are going to age and maybe experience some type of chronic illness, so we need to make sure we’re OK financially; make sure we have funds so that our retirement is OK; and buy into long-term care insurance because this helps with additional services that we might need.
Planning includes making a will and ensuring that everything is in place for our children, so they aren’t fighting and appointing a health care proxy—the person who is going to make health care decisions. These are things that we have to make sure we have in place.
In addition, it’s key to plan early. For example, as soon as you turn 65, find out—in the event you develop a chronic illness, such as Alzheimer’s—what requirements you must meet to be eligible for Medicaid, so that, later on, all your money isn’t depleted.