My mother is moving north from Florida. She has an HMO in Florida. What kind of insurance is available in Massachusetts?

Q: My mother is moving north from Florida. She has an HMO in Florida. What kind of insurance is available in Massachusetts?


A: Many HMOs allow seniors to drop out of the HMO during the year but some have restrictions. It is important to call the HMO to ask them what the guidelines are for leaving and what needs to be done to notify the HMO.


Here in Massachusetts, a senior can leave an HMO and go back to traditional Medicare. Your mother needs to find out if that also applies to Florida. If a senior is in a nursing home, then the change from an HMO to traditional Medicare can occur at anytime. If a senior is living in the community and wishes to cancel their HMO and to go back to traditional Medicare the change can only occur once a year. There is open enrollment at the end of the year and coverage begins the first of January.


In Massachusetts, there are many HMOs from which to choose. Some insurance policies are more inclusive than others so it is important to compare coverage and cost. HMOs have restrictions and some medical testing requires prior approval. Traditional Medicare does not have prior approvals and is the least restrictive choice.


In Massachusetts, it is important to have a supplemental policy with traditional Medicare. Blue Cross and Blue Shield is one option but there are others providing supplemental coverage. The supplemental coverage pays for charges after Medicare has paid their portion. For Medicare it is also federal law that you must have prescription coverage or Part D. The HMOs provide prescription coverage.


Many local senior centers have a SHINE program which offers information about seniors' medical coverage. They can be reached at 800-243-4636. Their expertise is in medical insurance coverage including prescription coverage. There is no charge for this service.


Q: How do I know when it is time to place my mother in a nursing home? I have provided care for my mother but she is now requiring even more help. My mother has dementia and is now incontinent. I want to keep my mother with me for as long as possible but when is the right time?


A: There is no right time. As dementia progresses the care increases and can signal a time for placement. If your mother is requiring hands-on help with at least four of the following: bathing, grooming, dressing, walking, transfers, eating and toileting care, then she meets the medical criteria for nursing home care.


For many families, when their relative is incontinent they begin the process of looking at nursing homes. It is a wise idea to begin to tour these facilities and inquire about the admissions process in the event that your mother has a hospitalization and cannot return home.


We suggest touring a few nursing homes. Look and observe how the staff interacts with the residents. Is the staff smiling? Are they asking the resident if they would like something? Are they explaining to the resident where they are going?


Spend time with the admissions coordinator to ask questions. Ask the same questions at all the facilities. As you tour, keep your mother in mind. If she enjoys listening to music, how often is music played in the facility? If your mother prefers to spend time by herself, ask if your mother can spend days in her room. You want the facility to match your mother's lifestyle.


ElderCare Resource Services is a partnership of geriatric nurses and social workers that helps families to investigate, assess and recommend medical and non-medical care and resources for seniors.


Send questions to SeniorSavvy@ElderCareResourceServices.com or ElderCare Resources Inc., 29 Gano Road, Marlborough, MA 01752, or call them at 508-879-7008.


MetroWest Daily News