Find a
Nursing Home
Residential Care
/ Assisted Living
CCRCs Medi-Cal for
Long Term Care
Elder Abuse
/ Financial Abuse
Find an Elder Law Attorney

Is it wise to keep your previous health care coverage
when you enter a CCRC?

By Lillian L. Hyatt, M.S.W., and a Resident of a CCRC

Excerpted from the Fall 2005 The CANHR Advocate newsletter

The Continuing Care Residential Communities (CCRCs) count on some residents retaining their outside health coverage because the CCRC health system is not large enough to serve all residents – a fact rarely mentioned to anyone entering a CCRC.

The CCRC’s healthcare services might not provide quality coverage. For example, a resident needing an immediate appointment with a doctor could be told to see a doctor other than his or her own. Sometimes a CCRC resident in the Skilled Nursing Facility is transferred to another unit of a CCRC chain due to lack of beds. When the resident is transferred to a CCRC’s Assisted Living section, medical visits do not take place regularly. And the in–house medical group servicing the CCRC will not see or care for HMO patients. Applicants should clarify these issues with the Director of Nurses (DON), not the Marketing Director, before signing a contract.

The Preferred Option: The best option is to become a private patient of a doctor in the medical group that services the CCRC, a visit usually covered by Medicare. In case the resident is unable to come to the primary care physician’s office, the physician can see the resident in his or her apartment. This option gives a CCRC resident the freedom to choose doctors and medical specialists, and still permits a resident to utilize the care their CCRC offers through its clinic and nursing staff in a medical emergency.

The monthly fee for the CCRC health care system is the same for all residents, even for those who do not use that system at all. However, if a resident chooses to do so, the resident can drop the outside health coverage in favor of full CCRC coverage. But the insurance premium for medi–gap insurance will be added to monthly care fees.

HMOs: Some residents retain HMO health plans such as Kaiser or Health Net because they wish to continue with their doctor and to obtain prescription benefits that CCRC’s do not offer.

For instance, as long as a resident can visit a Kaiser facility without assistance, this choice appears to work well. Kaiser’s prescription drug costs are low. However, some CCRC’s report difficulty in accessing the Kaiser medical staff if the resident is in the Assisted Living section. The Kaiser medical staff is not reimbursed for such visits, and is reluctant to come. In some cases, Kaiser has a signed contract with a CCRC permitting Kaiser doctors to see the enrolled patients if they are in the Skilled Nursing Facility.

Kaiser members who are CCRC residents and need long term care are not eligible to be placed in Kaiser facilities. Therefore, a CCRC resident may fall into what one Long Term Care Advocate called the “Double Crack.” The resident now has encountered a situation where the two systems, CCRC and Kaiser, appear to cancel each other out. No mention of this complex relationship is ever explained to an incoming CCRC resident.

Consumer Advice: Before changing existing healthcare arrangements outside the CCRC system, find out from the health care plan or HMO exactly what legal relationship the doctors and other healthcare professionals have with the CCRC. For members of HMOs, also determine what services medical professionals will provide if the resident is unable to go to the HMO. In addition, ask the DON exactly how your HMO works within the CCRC’s health care structure.