Benefits and Coverage

What kind of benefits and coverage do I receive with Elderhaus PACE?

As a participant in the Elderhaus PACE program, all necessary health services will be provided through Elderhaus PACE and your Personal Care Team. Most care is delivered at the Elderhaus PACE Center. Your Personal Care Team will decide with you and your family/caregiver on what is best for your needs.

Elderhaus PACE provides all normally covered Medicaid and Medicare services as well as additional services if needed.

Following are lists of examples of services Elderhaus PACE provides:

Outpatient Health Services

• Adult Day Center
• Physician, clinic, and specialist services, which may include advanced practice nurses. Female participants are entitled to choose a qualified specialist for women's health services from a Elderhaus PACE provider network to furnish routine and preventive care. Specialty services may include:

-Anesthesiology
-Audiology
-Behavioral Health services/mental health and substance abuse services including community psychiatric rehabilitation services
-Cardiology
-Dentistry
-Dermatology
-Gastroenterology
-Gynecology
-Internal Medicine
-Nephrology
-Neurosurgery
-Oncology
-Ophthalmology
-Oral Surgery
-Orthopedic Surgery
-Otorhinolaryngology (ear, nose and throat)
-Plastic Surgery
-Psychiatry
-Pulmonary Disease
-Radiology
-Rheumatology
-General Surgery and Ambulatory Surgery
-Thoracic and Vascular Surgery
-Urology

• Nursing Care
• Medical Social Services
• Physical, Occupational and Speech Therapy
• Podiatry
• Help for you and your family on how to choose and cook healthy foods
• Laboratory tests, X-rays and other tests used to find out what health problems you may have
• Prescribed drugs and medicines. You must get these through the Elderhaus PACE Center.
• Durable Medical Equipment (such as artificial limbs, hospital beds, wheelchairs, and walkers)
• Vision care (examinations and treatment including eyeglasses)
• Psychiatric Care including evaluation, consultation, diagnosis, and treatment
• Hearing Services, including evaluation, hearing aids, repairs and maintenance

Hospital Inpatient Care

• Semi-private room and meals
• General Medical and Nursing services
• Medical/Surgical, Intensive Care, Coronary Care units, as necessary
• Laboratory tests, X-rays, and other necessary tests
• Prescribed drugs and medicines
• Blood and blood parts such as plasma
• Surgical care including use of medicine that puts you to sleep during surgery
• Use of oxygen
• Physical, Speech, Occupational, and Respiratory Therapies
• Medical Social Services
• Emergency and Urgent Care
• Ambulance Service
• Treatment Room Services
• Dentures and Repair and Maintenance

Not included under hospital care are private room and private duty nurse charges, unless your Personal Care Team feels it is necessary for your condition. Also not included are non-medical items such as telephone charges unless they are authorized by the IDT.

Nursing Facility Care

• Semi-private room and meals
• Doctor and nursing services
• Custodial care
• Personal care and assistance
• Prescribed drugs and medicines
• Physical, Speech, and Occupational Therapies
• Medical Social Services
• Medical supplies and appliances
• Other services determined necessary by the IDT to improve and maintain the participant’s overall health status

Home Health Care

• Skilled nursing services
• Doctor's visits
• Physical, Speech, and/or Occupational Therapies
• Medical Social Services
• Home Health Aide services
• Homemaker/Chore service
• Home delivered meals with special diets.
• Respite Care
• Personal Care Services

End of Life Care

End of Life services will be coordinated between the participant and their family/caregiver and the Elderhaus PACE Personal Care Team. End of Life services may include any combination of care in the hospital, care in a nursing facility, and/or care at home.

Health-Related Services

Health related services include transportation, homemaker/chore services, personal care services, home delivered meals, help in getting around your community, and help in handling your money and paying your bills. Health related services will be coordinated and provided based on your plan of care.

Dental Care

Dental care will be given to you according to your needs. Your Personal Care Team will approve of the dentist who will care for your teeth and gums and will schedule any necessary appointments.

Dental services may include:

• Diagnostic services - examinations and tests, or X-rays, to see what your needs are
• Preventive services - cleaning and instructions in keeping your teeth and gums as healthy as possible
• Restorative dentistry - fillings, temporary or permanent crown(s)
• Prosthetic appliances - complete or partial dentures
• Oral surgery - pulling teeth (called “extracting”) or the removal or repair of soft and hard gum tissue

Second Medical Opinion

You and/or your family/caregiver are entitled to the opinion of a different health care provider if you so choose. If you and/or your family/caregiver would like a second opinion, you must ask Elderhaus PACE to coordinate and schedule this second opinion for you if you want Elderhaus PACE to pay for it.

You always have the right to appeal a Elderhaus PACE care decision.