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medicare hospice compare Does Medicare Cover Hospice?

Many people are still not very familiar with Medicare and hospice.  It is actually a fairly new idea.  The “end of life movement” began in the ’70s.  (The “end of life movement” is separate and distinct from the Euthanasia movement and organizations, like the Hemlock Society.)  Medicare did not cover Hospice when Medicare started in 1965.  Medicare and hospice were only put together in 1982 as part of the Tax, Equity, and Fiscal Responsibility Act under President Reagan in response to a growing awareness of end of life concerns.  The legislation was an attempt to fill the gap in care.  Awareness was growing in the country of the importance of what transpired at the end of life.

A Happy Death Is Not A New Ideamedicare hospice conditions of participation

I remember when I was a teenager.  My father was up before me in the mornings.  He would take me to school on his way to work.  I would see him praying when I came into the kitchen in the morning.  One time I asked him what he was reading.  It was a small devotional booklet.  He was praying the novena to St. Joseph for a “Happy Death.”  I was startled by the subject matter.

Teenagers don’t think much about death unless forced.  I had a buddy, Herbert Woltz, killed in a motorcycle accident my senior year in high school.  That was my abrupt intro to death.

I asked my father why pray for such a crazy thing as a “happy death”?  The two subjects were oxymoronic to me.  What’s happy about death?  He reminded me that is how the Hail Mary ends.  “Pray for us . . . now and at the hour of our death.  Amen.”

After birth, he said, death is the most important event in your life.  The difference, however, is you’re aware of what’s going on in the end, and you make the most important decisions of your life at “the hour of your death.”  Praying for a “Happy Death” is about minimizing the pain and maximizing your moment of entrance into eternity.  You’re asking for God and all the heavenly hosts to be at your side to handle the fear, pain, discouragement, and loneliness a person faces when approaching death and the moment of death.

I didn’t think much about what my father shared until many years had gone by and many friends and family members had passed away, including my dad.  Medicare and hospice are something with which I have had extensive experience.  Now I know why you would want to pay for a “happy death.”

End of Life Care Is Different

medicare hospice guidelines for dementiaAs a seminary student in St. Paul, Minnesota in the early 80’s, I was looking for a part-time ministry when I wasn’t at school studying.  I found the Hawthorne Dominicans.  The Hawthorne Dominicans is a Catholic women’s religious order devoted to the terminally ill.  They had a hospice facility near my college, so I would walk down to it and help out on weekends.  Most of the patients were cancer patients.  My work was minor cleaning, but mainly it was visiting with the patients.  Keeping up their spirits.  Show them someone cared as they were coming to the end of their lives, and I would join the sisters in prayer and mass for the residents.

While I was there, I got to know the sisters.  They were remarkable young ladies.  The convent was inside the hospice facility.  The nuns lived, prayed, and worked with their dying residents around them twenty-four hours a day.  The Hawthorne Dominicans were some of the happiest people I ever met.

Their foundress, Rose Lanthrop-Hawthorne, was the youngest daughter of the famous author, Nathanial Hawthorne, and a convert to Catholicism.  In her day, cancer patients were put on an island in New York harbor–Blackwell Island–because it was believed that cancer was contagious.  Many people, especially the poor, died in incredible misery, isolation, and squalor.

Medicare and hospice were a century away.  Rose, like Mother Teresa of our time, saw the face of Jesus in the poor, and she started a ministry to the dying among the poor immigrants of the New York slums.  The Hawthorne Dominicans is a purely American woman’s religious order.  Most woman’s religious orders in our country came from Europe originally.

End of Life Care Rediscovered With Hospice & Medicare

The end of life movement in our time found its origin during a 1967 lecture at Yale University by Cicely Saunders.  She introduced the idea that the dying needed specialized care that served their unique situation.  She later founded St. Christopher’s Hospice in London.

Dr. Elisabeth Kubler-Ross, MD research into death and dying identified five stages terminally ill patients go through.  Her popular and groundbreaking book, On Death & Dying, fueled a movement to deal with issues of death and dying.

In 1972 she testified at the first national hearings on death with dignity conducted by the U.S. Senator Special Committee on Aging.  Organizations, like The National Hospice and Palliative Care Organization (NHPCO), sprang up to study and promote awareness around the end of life issues.   Finally, because of raised public interest and concerns, Medicare added hospice care to the list of services provides in 1982.

Medicare And Hospice Are Huge

In 2014 approximately 2.6 million people died in the US.  Of those deaths, 80% were on Medicare.  Medicare is the largest insurer for persons during the last year ofmedicare hospice compare life.  A quarter of the Medicare budget is just for those who are in the last year of life.  That number has been consistent for decades.  The high cost of health care at the end of life is not surprising considering the number and complexity of health issues, so CMS (Center for Medicare & Medicaid Services) is acutely aware of end of life issues.

Today, hospice is an important benefit for terminally ill Medicare beneficiaries.  Currently, nearly half of Medicare beneficiaries receive hospice benefits before their deaths.  Medicare is the primary source of payment for hospice care in this country.  Yet, hospice still remains somewhat of a mystery, and Medicare beneficiaries know very little about what Medicare does with hospice until they are forced into the situation.

How Does Medicare Cover Hospice?

Hospice is defined as a program of care and support for people who are terminally ill.  Terminally ill means a life expectancy of six months or less.  The primary goal of hospice in Medicare is to help terminally ill people live a comfortable life and manage their pain and discomfort.  Hospice care is palliative care versus skilled nursing and home health care.  That is, it is not designed to cure the patient, but rather to aid the person in the dying process.  Because hospice care is so intimately involved and in such a big way with Medicare beneficiaries, understanding Medicare and hospice is essential.medicare advantage and hospice

Prayer to St. Joseph 

O St. Joseph whose protection is so great, so strong, so prompt before the throne of God, I place in you all my interests and desires. O St. Joseph do assist me by your powerful intercession and obtain for me from your Divine Son all spiritual blessings through Jesus Christ, Our Lord; so that having engaged here below your heavenly power I may offer my thanksgiving and homage to the most loving of fathers. O St. Joseph, I never weary contemplating you and Jesus asleep in your arms. I dare not approach while He reposes near your heart. Press Him in my name and kiss His fine head for me, and ask Him to return the kiss when I draw my dying breath. St. Joseph, patron of departing souls, pray for us. Amen.

John Joseph Grimmond 1934-2013  R.I.P.

What Is Medicare Hospice?

Does Medicare Pay For Hospice?
Does Medicare Pay For Hospice Care?

Medicare pays for hospice, but what is hospice exactly?

Medicare defines hospice as a program of care and support for people who are terminally ill.  Terminal illness, as Medicare definites it, is a life expectancy of six months or less.  The primary goal of hospice in Medicare is to help terminally ill people live a comfortable life and manage their pain and discomfort.  Hospice care is palliative care versus skilled nursing and home health care.  Hospice does not cure the patient but rather aids the person in the dying process.

Death & dying is an area most people do not wish to ponder, so there are many misconceptions about Medicare-covered hospice care.

What Medicare Hospice Is Not?

Hospice is not a place.  When my mother was terminally ill with ovarian cancer, I was thinking of taking her to a place.

what does medicare pay for hospice care

When I was in college in the 80s, I had volunteered in a hospice facility run by the Hawthorne Dominican sisters.  The hospice facility was an actual place people went to die.  The nuns took care of everything: medical, personal care, food & lodging; and patients stayed there until the end.

That is what I had in mind when the doctors spoke to my family about hospice for our mother.  That is not, however, how Medicare thinks of hospice. 

Medicare does not pay for a hospice facility that provides room & board unless the care is tied to something like a skilled nursing facility.  Medicare does, however, pay for hospice personnel and the medications they administer during hospice.

Where Do You Go For Hospice?

Hospice can be given virtually anywhere.  A Medicare beneficiary can receive hospice at a hospital, hospice in a skilled nursing facility, hospice in an assisted living residence, and hospice at home.  Medicare will pay for hospice care in assisted living, nursing homes, and other facilities if it is a Medicare-approved facility.

The end of life movement that started in the ’70s sees passing at home as the ideal.  Most Medicare patients, when surveyed, prefer hospice in the home.  That is where people feel most comfortable, but because of the level of care required, hospice care may have to move to a hospital in the last few days or another location.

Hospice can be given virtually anywhere. 

Medicare.gov

What Kind of Illness Makes You Hospice Eligible?

When we think of hospice, we usually think of cancer, but there are other illnesses that result in hospice.

Grandpa Joe was 98.  Grandpa had beaten cancer 4 times, lockjaw, and the Second World War.  Dying didn’t seem possible. He had always been there, and we grandkids assumed he would always be there. Terminal illness and Grandpa Joe didn’t fit. 

When Grandma Hilda announced to the family, Grandpa had congestive heart failure and was going into hospice, it didn’t quite register with us grandkids. 

Grandpa Joe seemed the same old Grandpa Joe. When I was home from college, we chatted about the Cornhuskers, baseball, and politics.  Nothing seemed to have changed, but there was a procession of nurses and therapists who came in and out of their home.

When Grandma Hilda finally called to tell us Grandpa had passed in his sleep, his death hit me like a sledgehammer.

Grandpa’s passing was hard on everyone, but Medicare providing and paying for hospice lightened the burden, especially for my parents and grandparents.

Does Medicare Pay For Hospice

Who Can Go Into Hospice?

Hospice is also not exclusively for the old.  I have a number of clients who are in their twenties and thirties.  Not everyone on Medicare is sixty-five and older, though the majority are. 

Accidents or illnesses permanently disabled some, and some are terminal.  Hospice is for them too.

How Much Is Hospice?

Hospice care is not expensive for those on Medicare.  Medicare pays for the vast majority of the hospice costs under Medicare Part A with very little out-of-pocket costs.  Medications, some equipment, and nurses are covered. 

Like I said earlier, hospice does not usually include custodial care or housekeeping.  That can be very costly if the family cannot provide that type of care themselves.

How Do You Get Medicare To Pay For Hospice?

A Medicare beneficiary is eligible for Medicare’s hospice care benefit if she is entitled to Medicare Part A and meets the following conditions.

  1. The hospice doctor and the person’s regular physician certify that the person is terminally ill with a life expectancy of six months or less if the illness runs its Does Medicare Cover Hospice?expected course.
  2. The person accepts palliative care for comfort instead of care to cure her illness.
  3. The person must sign a statement choosing hospice care instead of other Medicare-covered treatments for her terminal illness and related conditions.
  4. The care is provided by a Medicare-certified hospice agency.

When these 4 critical are met, Medicare pays for hospice. At any time, a person may choose to exit hospice.

Is Hospice Euthanasia?

Hospice does not accelerate the dying process. 

I have had people describe hospice to me as akin to euthanasia where someone actively terminates a life.  Hospice is not euthanasia or assisted suicide.  You do not intentionally cut short a person’s life.  Hospice is about allowing the dying process to take its natural and inevitable course without assistance.  Hospice care is about alleviating the suffering and providing comfort while the person dies.

Does Medicare Cover Hospice?

An uncle of mine was a retired Omaha police captain. Uncle Bill had a severe stroke with many complications.  He was put on a ventilator. 

Uncle Bill was a strong and courageous individual.  A vegetative existence was not for him not to mention impoverishing his wife with medical bills.  He ordered the ventilator turned off.

Without the ventilator, he would quickly stop breathing.  He knew it.  The doctors made him as comfortable as possible with heavy sedation.  His body fought hard against the loss of breath.

We gathered around his hospital bed.  Over the course of a day, he passed peacefully from this life to next surrounded by his loving wife and children.

Hospice Is Up To You

I’ve known many individuals over the years who have gone on hospice for a time.  Instead of dying, their health improved, or they resumed a normal life and quit hospice because the decline stopped.  You are free to remove yourself from hospice at any time.

Hospice Is Also For The Living

Hospice is the option when all other alternatives have been exhausted.  It is the option to bring the highest possible quality of life to a person’s remaining time.  The hope is family members will look back on their time and know that everything was done to preserve, prolong, and then peacefully say goodbye.

does medicare pay for hospice at home

While you may struggle with the challenge of terminal illness, the end of your life and hospice is as much about your loved ones as it is about you.  Watching you suffer and your family’s grief afterward will be their burden.  Dying is equally about them.  Understanding that there is something for them as well as you in a scary time can give you all hope that the last great challenge in life will be a little less daunting.

While hospice ends with a patient’s death, family grief counseling can continue for up to a year.  Medicare pays for that hospice care too.

One’s mortality is difficult to face, but the chance you will go on Medicare hospice at the end of your life is more than 50%.  That is an extraordinary number, so having confidence Medicare will pay for hospice is critical.

Medicare Mental HealthMental Health Among 60+

Older people on Medicare face unique physical and mental health care challenges which need to be recognized.  Over 20% of adults aged 60 and over suffer from a mental or neurological disorder (excluding headache disorders). Mental and neurological disorders among all disabled people over 60 years old are 6.6%. These disorders in older people account for 17.4% of Years Lived with Disability (YLDs).

The most common mental and neurological disorders in this age group are dementia and depression. This affect approximately 5% and 7% of the world’s older population, respectively. Anxiety disorders affect 3.8% of the older population. Substance abuse problems affect almost 1%.

Medicare suicide

In 2002, the annual suicide rate for persons over 65 was over 15 per 100,000 individuals; this number increases for those aged 75 to 84, with over 17 suicide deaths per 100,000. The number rises even higher for those over age 85. Further, elder suicide may be under-reported by 40% or more.

Not counted are “silent suicides,” like deaths from overdoses, self-starvation or dehydration, and “accidents.” The elderly also have a high rate of completing suicide because they use firearms, hanging, and drowning. Double suicides involving spouses or partners occur most frequently among the aged.

Mental health problems for Medicare beneficiaries are under-identified. Healthcare professionals and older people are reluctant to seek help because of the stigma associated.  Fortunately, Medicare does offer mental health benefits

Medicare Mental HealthMental Health Risk Factors Among Medicare Age Adults

There may be multiple risk factors for mental health problems at any point in life. Older people may experience life stressors common to all people, but the stressors are more common in later life. Conditions that cause stress are significant ongoing loss in capacities and a decline in functional ability.

For example, older adults may experience reduced mobility, chronic pain, frailty, or other health problems requiring some form of long-term care. In addition, older people are more likely to experience events such as bereavement or a drop in socioeconomic status with retirement. All of these stressors can result in isolation, loneliness, or psychological distress in older people, for which they may require long-term care.

Mental health has an impact on physical health and vice versa. For example, older adults with physical health conditions such as heart disease have higher rates of depression than those who are healthy. Additionally, untreated depression in an older person with heart disease can negatively affect its outcome.

Older adults are also vulnerable to elder abuse – including physical, verbal, psychological, financial, and sexual abuse; abandonment; neglect; and severe losses of dignity and respect. Current evidence suggests that 1 in 6 older people experience elder abuse. Elder abuse can lead to physical injuries and serious, sometimes long-lasting psychological consequences, including depression and anxiety.

Dementia 

Dementia is a syndrome, usually of a chronic or progressive nature, in which there is deterioration in memory, thinking, behavior, and the ability to perform everyday activities. Although it mainly affects older people, it is not a normal part of aging.

It is estimated that 50 million people worldwide live with dementia, with nearly 60% living in low and middle-income countries. The total number of people with dementia is projected to increase to 82 million in 2030 and 152 million in 2050.

Medicare DepressionDepression

Depression can cause great suffering and leads to impaired functioning in daily life. Unipolar depression occurs in 7% of the general older population. Depression is both underdiagnosed and undertreated in primary care settings. Symptoms are often overlooked and untreated because they co-occur with other problems encountered by older adults.

Older people with depressive symptoms have poorer functioning than those with chronic medical conditions such as lung disease, hypertension, or diabetes. Depression also increases the perception of poor health, the utilization of health care services, and costs.

What Medicare Covers For Mental Health?

Medicare coverage for mental health is not really different from physical health.  You can see a battery of doctors and mental health professionals: psychiatrists, clinical psychologists, clinical social workers, and psychiatric nurses.  Using the resources available to you, you can look up the Medicare mental health providers list to give you the complete picture.  You don’t need to rely on your primary care doctor alone (though they may be able to make some recommendations).  

Medical professionals may also order lab tests and psychiatric evaluations, and screenings to diagnose and treat.

The treatments generally fall under Medicare Part B because they are outpatient services mental health services: counseling, group therapy, outpatient treatment programs, and partial hospitalization. There is even family counseling available.

Medicare counseling

Opioid Use Disorder Treatment Services

The epidemic of opioid abuse has caused Medicare to focus on opioid misuse.  Services from Medicare include medication, counseling, drug testing, and individual and group therapy.

Alcohol Misuse Screening & Counseling

Medicare covers one alcohol misuse screening per year for adults with Medicare who use alcohol but don’t meet the medical criteria for alcohol dependency. If your health care provider determines you’re misusing alcohol, you can get up to 4 brief face-to-face counseling sessions per year (if you’re competent and alert during counseling). You must get counseling in a primary care setting (like a doctor’s office).

If you have a substance use disorder or a co-occurring mental health disorder, you can get telehealth services from home.

These outpatient services are usually provided outside a hospital (like in a clinic, doctor’s office, or therapist’s office) or in an outpatient department.  Partial hospitalization services can be provided in a hospital outpatient department or community mental health center.

What You Pay

With the Medicare mental health plan, after you pay the Medicare Part B deductible, you have a 20% coinsurance for medical professionals and outpatient services for out-of-pocket costs.  If you also have a Medigap policy, more of the cost will be covered depending upon the type of plan you have.  You need to consult the Evidence of Coverage for each Medicare Advantage plan to detail the costs and copays for mental health coverage.  Medicare mental health billing will enter the picture, and you’ll want to be ready.  

Medicare dementia Medicare Covers Partial Mental Health Hospitalization

You may need more intense help than can be rendered during office visits with a counselor. Partial hospitalization is a structured outpatient psychiatric service provided to patients as an alternative to inpatient psychiatric care in a psychiatric hospital.  It is more intense than the care you get in a doctor’s or therapist’s office.  This type of treatment is provided daily and doesn’t require an overnight stay.

Again, Medicare Part B would cover 80% of this cost after the Part B deductible, and Medicare Supplements would cover some or all of the 20%.  Medicare Advantage plans would cover a program as described in the Evidence of Coverage up to the maximum out-of-pocket.

Medicare Inpatient Mental Health Hospitalization

Inpatient mental health hospitalization is infrequent.  Most mental health treatment is conducted through outpatient programs and individual counseling sessions.  Inpatient mental health hospitalization, however, does happen.

The coverage and cost associated with inpatient mental health hospitalization are similar to regular hospitalization.  There is a deductible per event in 60 days.  The difference, however, is the limitation on the number of days.  While regular Part A hospitalization has additional days, inpatient mental health hospitalization is capped at 190 lifetime days.

Medicare Mental Health Prescription Drugs

Most Medicare drug plans list drugs that the plan covers called a formulary. Medicare drug plans aren’t required to cover all drugs, but they’re required to cover all (with limited exceptions)
antidepressant, anticonvulsant, and antipsychotic medications.  Medicare reviews each plan’s formulary to ensure it contains a wide range of drugs and doesn’t discriminate against certain groups (like people with disabilities or mental health conditions).

Mental health is a growing problem among seniors.  Medicare covers screenings, diagnostic treatment, counseling, treatment programs, and even hospitalization.  Medicare covers most of the costs, with Medigap and Medicare Advantage plans covering or limiting the coinsurance.

For those concerned about mental health issues and insurance coverage, Medicare provides comprehensive coverage at low costs.

Cataracts Are Common Among Seniors: Does Medicare Cover Cataract Surgery? 

Does Medicare Cover Cataract Surgery Over 24 Million Americans have cataracts–and worse, the risk of cataracts increases each decade of life, starting around age 40. Statistically, as many as 50 percent of Americans over 75 will be diagnosed with cataracts, and by 80, that number has grown as large as 70 percent.

The good news is, Medicare does cover cataract surgery!

What Are Cataracts?

Before we discuss the Medicare requirements for covered cataract surgery, let’s first examine what cataracts are.  Most simply, a cataract is a cloudy area in the lens of your eye. At first, you may not notice that you have a cataract.  But over time, cataracts can make your vision blurry, hazy, or less colorful. You may have trouble reading or doing other everyday activities.

What Are the Types of Cataracts?

There are a few different types of cataracts.  Most cataracts are age-related — they happen because of regular changes in your eyes as you get older. But you can get cataracts for other reasons — for example, after an eye injury or after surgery for another eye problem (like glaucoma).

What’s the Treatment for Cataracts?Does Medicare Cover Cataract Surgery

Surgery is the only way to get rid of a cataract, but you may not need to get surgery right away.  This is a crucial distinction when it comes to Medicare requirements for covering cataract surgery, as we’ll examine below.  

During cataract surgery, the doctor removes the clouded lens and replaces it with a new, artificial lens (also called an intraocular lens, or IOL). This surgery is very safe, and 9 out of 10 people who get it can see better afterward.

Am I at Risk for Cataracts?

Your risk for cataracts goes up as you get older. You’re also at higher risk if you:

    • Have specific health problems, like diabetes
    • Smoke
    • Drink too much alcohol
    • Have a family history of cataracts
    • Have had an eye injury, eye surgery, or radiation treatment on your upper body
    • Have spent a lot of time in the sun
    • Take steroids (medicines used to treat a variety of health problems, like arthritis and rashes)

If you’re worried that you might be at risk for cataracts, talk with your doctor. Ask if there is anything you can do to lower your risk.

Does Medicare Cover Cataract Surgery

What Does Medicare Require to Cover Cataract Surgery?Does Medicare Cover Cataract Surgery

For Medicare to cover cataract surgery or any other medical procedure, it must be “medically necessary.” Your doctor will probably suggest cataract surgery if you have vision loss that gets in the way of everyday activities like reading, driving, or watching TV.

Sometimes, your doctor might recommend cataract surgery even if your cataracts aren’t the leading cause of your vision problems. For example, the doctor might remove cataracts so they can see the back of your eye. If you have another eye condition, like diabetic retinopathy or age-related macular degeneration (AMD), your doctor will need to see the back of your eye to help you manage it.

While Medicare requires that cataract surgery be medically necessary, that’s not the same as being urgent. Cataracts are not a medical emergency, and you don’t need to rush to have surgery to remove them. Ask your doctor about the risks and benefits of cataract surgery to decide if it’s is right for you.

How do I Prepare for Cataract Surgery?

Does Medicare Coverage Cataract Surgery

At your doctor’s office before the day of the surgery, your doctor will do some tests to measure the size and shape of your eye. You may need to use some special eye drops before the surgery, and your doctor may tell you not to eat anything the night before your surgery.

You won’t be able to drive yourself home after the surgery, and you’ll need a friend or family member to make sure you get home safely — so be sure to bring someone with you.

If you have cataracts in both eyes, you’ll need to have surgery on each eye at a separate time, usually about four weeks apart.

What Happens During Cataract Surgery?Medicare Pays for Cataract surgery

The doctor will remove the cloudy lens from your eye during surgery and replace it with an artificial lens (called an intraocular lens). The surgery lasts about 1 hour and is almost painless.

Usually, you will be awake during cataract surgery. You might notice lights or motion, but you won’t be able to see what your doctor is doing.

When you get this surgery, your doctor will:

    • Put numbing drops into your eye to keep you from feeling anything
    • Use tiny tools to cut into your eye, break up the lens, and take it out
    • Place the new artificial lens in your eye

Right after surgery, you will need to rest in a recovery area outside the operating room for a little while. Before you go home, the medical team will check to make sure you don’t have any problems with your eye.

What Happens After Cataract Surgery?

Your doctor will explain how to protect your eye after cataract surgery. They will give you eye drops to help your eye heal, and you may need to wear a special eye shield or glasses. You may need to avoid some activities for a few weeks, like touching your eye, bending over, or lifting heavy things.

Your eye may feel a bit itchy or uncomfortable and sensitive to light and touch. After 1 or 2 days, your eye should feel better.

Call your doctor right away if you notice any of these problems after surgery:

  • Vision loss
  • Bad pain that won’t go away even if you take medicine for it
  • Very red eyes
  • Flashes of light or a lot of small dark spots or squiggly lines that float across your vision (floaters)

Most people are entirely healed eight weeks after their surgery. Your doctor will schedule checkups to make sure your eye is healing correctly.

Will My Vision be Normal after Cataract Surgery?Medicare Part B covers Cataract surgery

About 9 out of 10 people who get cataract surgery see better afterward, but your vision might be blurry at first while your eye recovers.

Some people notice that colors seem brighter after cataract surgery. The brighter color is because the artificial lens is clear, while your natural lens had a yellow or brown tint from the cataract.

Once your eye is completely healed, you might need a new prescription for glasses or contact lenses to see clearly.

What Are the Risks of Cataract Surgery?

Medicare Part B covers Catatract surgeryCataract surgery is one of the most common, safe, and effective types of surgery done in the United States. But like any surgery, there are risks, including:

  • Swelling, bleeding, or infections
  • Vision loss or double vision
  • Unusual changes in eye pressure
  • Retinal detachment
  • Secondary cataract (posterior capsule opacity)

Your doctor can treat these problems if they catch them early. Be sure to go to all of your checkups, and call your doctor if you notice anything wrong with your eyes or vision.

Is Cataract Surgery Covered Under Medicare Part B?

Cataract surgery is an outpatient procedure. You do not need to be admitted to the hospital usually, and you probably will not stay overnight.  So cataract surgery falls under Medicare Part B. Medicare covers cataract surgery, and pays for glasses and contact lenses after the surgery, if necessary.  

What Does Medicare Pay for in Cataract Surgery?

Because it is outpatient surgery under Part B, Medicare will pay 80% of the cost of your cataract surgery. You will be responsible for the 20% coinsurance. If you go to the Procedure Price Lookup on the Medicare website, you can see the approximate amount Medicare covers for cataract surgery and how much you will need to pay out of your pocket you pay for the procedure.

If you have a Medicare Supplement or Medigap policy, the policy will pay some or all of the coinsurance after the Part B deductible is met depending on your type of Medigap policy, (e.g., Plan G, Plan N, etc.).

With Medicare Advantage, the Evidence of Coverage lists cataract surgery and other outpatient procedures in the booklet for each plan with the copay. In the Benefit Highlights in the enrollment handbook for each MA plan, outpatient procedures are listed. This can help you to understand how much Medicare Advantage will cover for your cataract surgery and what you will pay.

Medicare AdvantageHow Much Should I Expect to Pay for Cataract Surgery If I Have Medicare?

In the Omaha-Lincoln-Council Bluffs Metro area, the cost from a Medicare Advantage plan for a beneficiary ranges from $250-$400 per eye, assuming you get the most common procedure.

According to the Procedure Price Lookup tool, without a Medicare Supplement and only Medicare Part B, the cost of your cataract surgery would be around $316 for an Ambulatory Surgery Center and $524 for a Hospital Outpatient Department. There are nine possible types of cataract surgery for which Medicare pays. Medicare lists each procedure with nine different billing codes.  There are even more options that are not listed.

Does Medicare Cover Cataract Surgery and Implants?

Medicare covers the total cataract procedure: doctor services, facility services, and medical devices (lens, drops, suture, etc.).  Medicare authorizes the use of standard lens prostheses.   

If the patient wants something more than Medicare’s standard lens, there will likely be an additional cost. The doctor’s billing office will explain and is required to have you sign off on, any non-Medicare additional costs of your cataract surgery before performing the procedure.

Clients Let Me Know Medicare Covers Cataract Surgery

Medicare covered outpatient surgeriesMany clients will call to find out whether Medicare covers cataract surgery and how much they should expect to pay based on their plan.  They’ll also call afterward to tell me how it all went.

Cataract surgery is a topic that I get called about often. It amazes them how little cataract surgery costs for both those on Medicare Advantage or a Medigap policy.

omaha Nebraska medicare insurance agent

Christopher Grimmond

If you would like to know more about your options for coverage under a Medicare Advantage plan or a Medigap plan, contact OmahaInsuranceSolutions.com 402-614-3389 today and speak with a licensed agent!

 

 

 

 

 

Does Medicare Advantage Pay for Home Health CareMedicare Advantage and Home Health Care

All Medicare Advantage (MA) plans must provide at least the same level of coverage for home health care as does Original Medicare, so Medicare Advantage pays for home health care.  However, an MA plan may have different rules, costs, and restrictions on services.  For example, depending on a person’s MA plan, it may require him to:

  • Obtain care from a home health agency that has contracted with the plan.
  • Receive prior authorization or a referral before receiving home health care.
  • Pay a copayment for home health care.

Coverage of Non-Skilled Care and Other In-Home Support Services

Center for Medicare & Medicaid Services (CMS) recently announced that Medicare Advantage plan will be able to cover certain types of home health care related services that were not previously able to be offered, beginning in 2019.  This will be possible because CMS has expanded the definitional scope of “supplemental benefits” that Medicare Advantage plans can offer.  Starting in 2019, insurers can offer additional services to help improve enrollees’ health and quality of life.

Medicare Advantage Can Pay for Home Health Care Supplemental BenefitsDoes Medicare Advantage Pay for Home Health Care

Medicare Advantage plans may offer additions benefits not offered by Original Medicare.  Previously, CMS did not allow any item or service to qualify as a supplemental benefit.  Supplemental benefits were items of “daily maintenance.”  In other words, MA plans could not offer items and services that were not directly for medical treatments.  The agency has now reinterpreted the requirement for supplemental benefits to include a “primarily health-related” definition as follows:

an item or service that is used to diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization

Some Medicare Advantage Supplemental Benefits

Accordingly, this reinterpretation of supplemental benefits will allow Medicare health plans to offer coverage or benefits for the following:

  • Adult daycare services  are services provided outside the home, such as assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs)
  • In-home support services are services a personal care attendant provides.  She assists disabled or medically needy individuals with activities of daily living, such as eating, bathing, and transferring, and instrumental activities of daily living.  These activities may include managing money, preparing meals, and cleaning a house.  Services must be performed by individuals licensed to provide personal care services, or in a manner that is otherwise consistent with state requirements.
  • Home-based palliative care services Medicare does not cover if life expectancy is more than six months.  Palliative care (“comfort care”) is to diminish symptoms of a terminally ill patient.
  • Transportation for nonemergency medical services is transportation to obtain Part A, Part B, Part D, and supplemental benefit items and services.  The Medicare Pay for Transportation transportation must be used to accommodate the enrollee’s health care needs: it cannot be used for nonmedical services, such as groceries or errands.
  • Home safety devices and modifications are safety devices to prevent injuries in the home and/or bathroom.  The modifications must be non-structural and non-Medicare covered.  This benefit can include home and/or bathroom safety inspection to identify any need for safety devices or modifications.

A physician or licensed medical professional must recommend these home care services.

Medicare’s expansion of MA plan benefits, like adult days care, helps patients remain in their homes as they age rather than being institutionalized, which could also result in lower costs for Medicare and Medicaid.

Medicare Advantage Home Health AideThe Advantage of Medicare Advantage for Home Health Care

Medicare Advantage plans may impose different rules, limitations, and costs than Original Medicare, but they must provide at least the same level of home health care benefits.

Starting in 2019, Medicare Advantage plans may offer supplemental benefits that help enrollees with daily maintenance, including transportation for medicare services, in-home support services, and home-based palliative care.  Consult the individual MA plan for the details of coverage.

In the Omaha metro area, the MA plans offer some of these benefits.  Currently, the plans that do offer a lot of these benefits are the “Dual” or “Special Needs” plans.  Those plans are for a person on full Medicaid as well as Medicare or have some special needs because of chronic illness, such as COPD, Diabetes, etc.

In other areas with high population densities, many of the MA plans are much richer with benefits.  As it stands in eastern Nebraska and western Iowa, principally Omaha, Lincoln, Bellevue, and Council Bluffs, the supplemental benefits seem to be growing in number and scope each year.  A couple of insurance companies recently added transportation to their health plans.  More insurance companies are developing Medicare Advantage plans and including this type of home health services.

Home Health CareHome health care is like it sounds. It is the care that takes place in the home.  Home health care consists of a wide range of services, like physical therapy, occupational therapy, speech therapy, and nursing care.  But, how long does Medicare pay for home health care?

The purpose of home health care is short term treatment for an illness or injury, such as a stroke or broken hip. It is about getting the person healthy and independent again.  For the chronically ill and disabled, the goal is to maintain the highest level of ability and health.

Home health care is not home care. Home care would be services, like housekeeping, bathing, feeding, etc.   Medicare does not usually provide those types of personal services, strictly speaking.

There are exceptions at times that allow for a temporary home health aide.  It is skilled nursing care provided in the home for those who would not have access otherwise.  While an excellent service, the big question is: how long does Medicare pay for home health care?  Some injuries and illnesses may last for a long time.

Medicare Home Health Care Coverage Benefit

Medicare Part A and Part B both provide coverage for home health care.  Under Part B, a person is eligible for home health care if she is homebound, requires skilled care, and is certified as needing care by a physician.  Medicare Part B covers most home health care.  The added benefit is Part B does not require a qualifying hospital stay.

Medicare Part A Coverage

Part A, in contrast, does provide home health care coverage in some situations.  A hospital or skilled nursing facility stay triggers Part A.  If a person has aHow Long Does Medicare Pay for home health care three-day inpatient stay at a hospital or has a Medicare-covered SNF stay, Part A will cover up to 100 days of home health care.

Note that a person must still meet the other eligibility requirements to receive home health care, such as needing skilled care, being homebound, and having a doctor certify that such care is necessary.  A person also must receive home health services within 14 days of being discharged from a hospital or SNF.  If a person doesn’t meet all of the requirements for Part A coverage but is otherwise eligible for home health care benefits, her care will be financed under Part B.

Medicare Coverage Amounts

Regardless of whether Part A or Part B covers a person’s care, Medicare will pay:

  • the entire approved cost of all covered home health visits
  • 80 percent of the Medicare-approved amount for durable medical equipment

Certified Home Health Agency Disclosure of Covered Costs

Before home health care starts, the certified home health agency must tell the person how much Medicare will pay. The agency must also disclose if Medicare does not cover needed items or services.  Then tell how much the person will have to pay for them.

For example, charges to a person may be:

  • medical services and supplies that Original Medicare doesn’t cover, such as prescription drugs or routine foot care
  • 20 percent of the approved amount for Medicare-covered durable medical equipment such as wheelchairs, walkers, and oxygen equipment

Home Health Agency Advance Beneficiary Notice of Noncoverage

When a certified home health agency believes that Medicare may not pay for some or all of a person’s home health care, it must give the person a written notice called an Advance Beneficiary Notice of Noncoverage (ABN).  The ABN might occur, for example, if the home health agency thinks that Medicare will not pay for items or services because:

  • The care is not considered medically reasonable and necessary.Does Medicare Pay For Hospice In A Skilled Nursing Facility?
    The care is only unskilled, a home health care aide, like help with bathing or dressing.
  • The person is not homebound.
  • The person does not need skilled care on an intermittent basis.

The ABN must describe the service and/or items that may not be covered and explain why Medicare probably won’t pay.  The notice must also include an estimate of the costs for the items and services, so that the beneficiary can decide whether to receive the services, understanding that she may have to pay out-of-pocket for such care.

The ABN also gives directions for getting an official decision from Medicare about payment for home health services and supplies and for filing an appeal if Medicare won’t pay.

Home Health Care Length of Coverage

There is no limit to the length of time that a person can receive home health care benefits. Once the initial qualifying criteria is met, Medicare will cover home health care as long as it is medically necessary.  However, care is limited.  There are a maximum number of visits per week and number of hours per day of care.

When a person first begins receiving home health care, the plan of care will allow for up to 60 days.  At the end of this period, the physician must decide whether to recertify the patient for another 60 days.  The patient must be recertified at least every 60 days if home health care is to continue.

Medicare does not limit the number of times that a physician may recertify a patient for home health care benefits, provided all of the eligibility requirements continue.

How Long will Medicare Pay for Home Health Care?

How much does Medicare Pay for skilled nursingA home health agency must give a beneficiary a written Home Health Change of Care Notice (HHCCN) when the patient’s plan of care is changing because the home health agency makes a business decision to reduce or stop providing some or all of the home health services or supplies.

The person’s doctor has changed the person’s orders, which may reduce or stop certain home health care services or supplies that Medicare covers.

For example, the agency issues an HHCCN when the doctor changes the plan of care from five days a week to three days a week.  The beneficiary must be notified in writing of the change of service.

The HHCCN lists the services or supplies that will be changed and gives the beneficiary instructions on what to do if she does not agree with the change.

The home health agency is not required to give a person an HHCCN when a Notice of Medicare Noncoverage is issued.

Notice of Medicare Noncoverage

When all of a person’s Medicare covers services are ending, the home health agency must give the beneficiary a Notice of Medicare Noncoverage (NOMNC).  This notice states when services will end as well as how to appeal the decision.  The NOMNC also provides information on how to contact the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) to request an expedited appeal.

Medicare skilled nursing facility requirementsOnce a person decides to appeal and has reached the BFCC-QIO, the home health agency must give the patient a more detailed notice explaining why it believes Medicare-covered care should end. The agency should tell the applicable coverage rules and other information specific to the person’s situation.

A physician must submit a statement of appeal to the BFCC-QIO that the patient’s health will be jeopardized if care is discontinued.

All of these factors go into how long Medicare pays for home health care.  Knowledge of these rules is important so that you can maximize your benefits and avoid costly mistakes.

 

Does Medicare Cover Home Health Care?Medicare covers Home Health Care, but the Medicare beneficiary must meet particular criteria, maintain a status of medical need, and follow Medicare regulations and processes to enjoy the benefits.

Eligibility For Medicare Home Health Care Benefits

  1. A physician must certify that skilled care is needed and must prescribe the plan of care.
  2. A participating Medicare-approved home health care organization must provide the care.
  3. The patient must need at least one of the services: intermittent skilled nursing care, physical therapy, speech-language pathology, and continued occupational therapy.
  4. The patient must be confined to the home.

Plan of Care

A physician must meet face-to-face with the patient 90 days before the start of home health care or within 30 days after the start of home health care.  She must sign and date a certification that the patient needs skilled care and meets all the Medicare eligibility criteria for home health care.  As part of the certification, she must determine from the in-person meeting a plan of care.Skilled Nursing Facility Medicare

  • A plan of care describes the type of services and care a person will receive for their health concerns.  The program will list:
  • the variety of services, supplies, and equipment needed.
  • the health care professional who will deliver these services
  • how often services will be needed
  • the beneficiary’s function limitations
  • nutritional requirements]
  • the results that the physician expects from the treatment

The home health agency is responsible for providing all of the care listed in a person’s plan of care.  The agency may do this through its staff or an arrangement with another agency.

The doctor certifies the person as eligible for an initial 60-day benefit period.  At the end of the period or before, the doctor may recertify the person, or if the person’s condition has changed, determine the care is no longer needed.  Only the doctor can certify the patient or make changes to the plan of care, not the home health agency.

Medicare Skilled nursing facility daysMedicare-Certified Home Health Care Agency

Medicare will pay for home health care only if a Medicare-certified home health care agency provides it.  Medicare approves agencies that meet specific federal health and safety requirements as well as Medicare standards necessary for reimbursement. To ensure that these standards met, Medicare regularly inspects home health agencies.  However, Medicare certification does not guarantee a legal warrant of the individuals performing the services.

A Medicare-certified home health agency agrees to:

  • be paid by Medicare
  • accept only the amount that Medicare approves for its services.

The patient has the right to choose any agency to provide the services as long as they are Medicare certified.  The agency is not required to accept the person if it cannot meet that person’s medical needs.

Skilled Care Required But Intermittent

To qualify for Medicare provided home health care, the person needs specialized care.  Skilled care means services, such as skilled nursing care, physical therapy, speech therapy, and/or continuing occupational therapy.

The key to determining home health care versus skilled nursing care in a facility is the quantity of care.  Home health care must be intermittent.  That is, the care must be part-time, meaning less than eight hours each day for up to 21 days–although coverage may be extended in particular circumstances when the need for additional skilled nursing is finite and predictable.

Required HomeboundDoes Medicare Cover Home Health Care?

The homebound criterium does not mean the person is a prisoner in her home.  It means leaving is an undue burden.  She has trouble leaving home without help because she must use a cane, wheelchair, walker, crutches, or specialized transportation.

It does not mean that person does not leave home on occasion because of important family events, specific medical tests, funerals, or weddings.  Even attending adult daycare would not be a violation of being homebound.

Home Health Care May Cover A Health Aide

Home health aide services get a great deal of play.  Medicare will cover a health aide for short periods.  The aide service must be coupled with home health care Does Medicare Cover Home Health Care?services.  Medicare does not cover it exclusively.

The home health aide is in support of the healing process with the other skilled nursing professionals. The home health aid does not have a nursing license.  For example, a home health aide might help a person with personal care, such as bathing, using the toilet, or dressing–in other words, services that do not require the skills of a licensed nurse.

Other services are help with medications that are self-administered, assistance with activities that are directly supportive of skilled therapy.  The aide may help with routine exercises and/or practicing functional communication skills.  Where appliable, she may help with regular care of prosthetic and orthotic devices.  Medicare will not cover the home health aide if the patient is not receiving skilled care.

Home Health Care Can Cover Social Services

Many injuries and illnesses come with an emotional cost.  A patient of my wife recently was hospitalized because his son assaulted him while under the influence of illegal drugs.  He was defending his wife, who was likewise being assaulted.  The father was hospitalized with broken bones.  He is also currently going through chemotherapy treatment and is eighty-six years old.

As you can imagine, the emotional trauma to this couple was extensive and may require counseling and other intervention when the gentleman returns home.  Home health care provides these types of services as well.

Skilled Nursing FacilityDurable Medical Equipment

Home health agencies will also help with durable medical equipment.  A patient may need a hospital bed, walker, wheelchair, or oxygen.  Medicare also covers Medicare supplies, like wound dressings or catheters that are ordered as part of a patient’s care.

If a home health agency doesn’t supply durable medical equipment directly, its staff will typically arrange for a home equipment supplier to bring the items need to the person’s home.

Does Medicare Exclude Some Home Health Care Services?

Medicare does not pay for the following:

  • 24-hour-per-day care at home
  • meals delivered to the home
  • homemaker services like shopping, cleaning, and laundry
  • personal care given by home health aides (like bathing, using the toilet, or help in getting dressed)when this is the only care needed.

Does Medicare cover home health care?  It certainly does when the patient meets the established criteria.  Home health care is a rich source of benefits to beneficiaries that are delivered in a variety of ways and circumstances as needed.

 

We know what hospitals are. We all have been to a doctor’s office. Many have experienced a relative in a nursing home, but what is home health care?

Home health care is like it sounds. It is the care that takes place in the home.  It consists of a wide range of services, like physical therapy, occupational therapy, speech therapy, and nursing care.

The purpose of home health care is short term treatment for an illness or injury, such as a stroke or broken hip. It is about getting the person healthy and independent again. Or, it is for the chronically ill and disabled. The goal is to maintain the highest level of ability and health.

Home health care is not home care. Home care would be services, like housekeeping, bathing, feeding, etc. Medicare does not usually provide those types of personal services, strictly speaking, though there are exceptions at times that allow for a temporary home health aide.  It is skilled nursing care provided in the home for those who would not have access otherwise.

Does Medicare Cover It?What Is Home Health Care?

Four criteria must be met for Medicare to pay for home health care.

  1. A physician must certify home health care is necessary.
  2. The home health care provider must be a Medicare-approved organization.
  3. The patient must need at least one of the following: skilled nursing care, physical therapy, occupational therapy, or speech therapy.
  4. The patient must be homebound.

Doctor Certifies Patient For Home Health Care

The doctor must certify a patient needs home health care during an in-person meeting. He signs a certificate certifying that the person meets the Medicare qualification. The doctor lays out a plan of care that care professions implement, and the certification is for 60 days. At the end of the 60 days, or before, he can recertify that patient for an additional 60 days.

The doctor can continue to recertify the patient indefinitely as long as the person qualifies for the medically necessary treatment, and Medicare will continue to cover them.

Home Health Agency Medicare Certified

The home health agency providing the care must be certified by Medicare for the service to be Medicare-covered. In my office building as you come in, a care agency is in the lobby. On the office door, the home health agency lists the various services, and in even bigger letters, it states, “Medicare Certified.”

Medicare certification of a home health agency is an extensive process. Because accreditation is arduous and a source of considerable revenue, home health agencies are very careful about maintaining their certification and advertising their Medicare certification as well. The Omaha metro area has some excellent home health care agencies.

Intermittent Care

Home health care must also be intermittent care. That is, it consists of fewer than seven days a week, or daily care for less than 8 hours each day for up to 21 days. Otherwise, a skilled nursing facility would most likely be recommended for a more intense regimen of care.

Homebound

What Is Home Health Care?The patient must be homebound, which means she cannot leave her home without great difficulty and requires help, such as a wheelchair, walker, crutches, or specialized transportation. It doesn’t mean she can never leave her home for important things, like family events, hairdressing appointments, some doctors’ appointments, but getting regular health services outside the house would be an undue burden.

People are living longer. Tremendous advances in technology have enabled seniors to stay out of expensive skilled nursing care.  Nowadays, patients may receive very sophisticated treatment at home and do not need to be institutionalized, keeping the cost of treatment lower. It is an important and essential service that Medicare covers.

Jimmo vs. Sebelius On Skilled Nursing

Skilled Nursing Care is amazingly complex. Because the Medicare coverage of Skilled Nursing Facility stays is so confusing, patients sued.  The case went all the way to the Federal Courts. Jimmo vs. Sebelius, a class-action lawsuit, challenged the Center For Medicare & Medicaid Services (CMS) interpretation of the “improvement stand” that many used to interpret Medicare coverage of Skilled Nursing Facility booklet.

Medicare Coverage of Skilled Nursing Facility Stays: Improvement Standard

Medicare Coverage of Skilled Nursing Facilities This one hit home for me because of how it affected my mother and our family. My mother was in the last stages of ovarian cancer. It became clear that no treatment was going to work. She was on palliative care. During one of her episodes, she was in extreme pain. The hospital admitted my mother because intravenously administered pain killers were the only way to get her pain under control. After that, she was supposed to come home. But her condition was such that we were not going to be able to care for her adequately. We talked about a nursing home—skilled nursing—but one of the criteria at the time was the patient must be able to improve. Because she was terminal, improvement was definitely not in the cards. We were initially told that Medicare would not pay for her stay in a skilled nursing facility. However, that was not accurate. The people we were talking with were operating off old, outdated information.

Slow Deterioration of a Condition

On January 24, 2013, the class action lawsuit Jimmo vs Sebelius settled in favor of the patient, and the Center for Medicare & Medicaid Services (CMS) clarified its policy.  Medicare coverage of Skilled Nursing Facility stays no longer required “improvement.”  Instead, care could be prescribed to maintain the status of an individual’s condition, or slow the deterioration of a condition, as well as to improve the person’s condition.

Jimmo Website Explains New Medicare Coverage

As ordered by the federal judge in Jimmo v. Sebelius, the Centers for Medicare and Medicaid Services (CMS) published a new webpage containing important Jimmo vs. Sebelius information about the Jimmo Settlement on its CMS.gov website. The Jimmo webpage is the final step in a court-ordered Corrective Action Plan.  The action reinforces the fact that Medicare does cover skilled nursing and skilled therapy services needed to maintain a patient’s function or to prevent or slow decline. Improvement or progress is not necessary as long as skilled care is required. The Jimmo standards apply to home health care, nursing home care, outpatient therapies, and, to a certain extent, for care in Inpatient Rehabilitation Facilities.

In my mother’s case, the skilled nursing facility admitted my mother, even though she was terminal, to help slow the deterioration of her health. As it turned out, she passed away within two weeks of her admittance, and the personnel at her skilled nursing facility were outstanding! They made her last days as bearable as the situation would allow.

Medicare Coverage of Skilled Nursing Facilities Changed

Skilled Nursing CareMedicare coverage of Skilled Nursing Facility stays practices have changed.  Researchers assessed the impact of the Jimmo settlement by looking at changes to the number of physical therapy and/or occupational therapy visits per year, per patient, focusing specifically on the number of individuals who had 12 or more therapy visits during a 12-month timespan.

Healthcare is very expensive. There are many conflicting groups and interests. The rules, policies, and mechanisms are complex. Some of the people you deal with can be frustrating. The complexity of the system is driven home to me daily as I talk with clients and deal with issues that arise. You need to be aware of the rules and regulations around Medicare coverage and nursing home care. Or have someone who knows them and can help.

Medicare Coverage For Skilled Nursing Facilities

Skilled Nursing Facilities—or better known in the jargon of Medicare as SNF—is the cause of much consternation among people on Medicare.  The reason for the Skilled Nursing Facility Medicare Covereddistress and stress is because Medicare beneficiaries are sometimes denied coverage.  This both confuses and angers Medicare beneficiaries because there doesn’t seem to be any rhyme or reason to the denials.  People ask: does Medicare cover Skilled Nursing Facility?

Medicare Billing Guidelines For Skilled Nursing Facility

From my observation over the years, doctors’ offices sometimes don’t follow the Medicare billing guidelines for Skilled Nursing Facility.  I understand everyone is busy and people are certainly well-intentioned, but Medicare is insurance.  Insurance has rules, protocols, and forms.  A lack of adequate explanation to Medicare is many times the cause of Medicare denials, I’ve seen over the years.  Other times the situation does not meet the Medicare criteria for Skilled Nursing Facility stays.

What are the Medicare Skilled Nursing Facility Requirements?

Skilled Nursing Facility Medicare CoveredWhen skilled nursing is prescribed, five Medicare Skilled Nursing Facility requirements must be met.  The first is a qualifying hospital stay.

The Medicare beneficiary must stay as an inpatient for three consecutive days in the hospital.  Each of these is an essential ingredient.  The beneficiary must be admitted to the hospital.  If the patient is only admitted for “observation,” she will not qualify.  She must be an “inpatient.”  Next, the stay must be consecutive.  It can’t be a day or two within a short period of time.  It must be at least 3 consecutive days.  And finally, it must be at least 3 days, not counting the day of dismissal.

Many times, people assume the day of dismissal counts, but that is definitely not the case.  Three days of inpatient care at least with a fourth day for the dismissal.  Sometimes people will complain that the patient doesn’t need a third day, but if you want the person to qualify, she must stay at least three consecutive days.

Medicare Skilled Nursing Facility Benefit Period

The second ingredient for Medicare to cover a skilled nursing facility stay is the admittance must occur with 30 days of dismissal from the qualifying hospital stay.

Skilled Nursing Facility Medicare Covered My mother-in-law had open heart surgery a while back.  Her cardiologist prescribed that she stay in a skilled nursing facility for cardiac rehab.  She was not a very cooperative patient.  She refused.  My wife was insistent and explained that if she didn’t go then, she would lose the opportunity for skilled nursing rehab.  My mother-in-law’s response was she would do it later if she needed it.

Many people mistakenly think they can go to a nursing home for rehab if they simply want to.  It must be within the 30-day window after dismissal from an inpatient stay.  Otherwise, Medicare will not pay.  Now you may think it is not fair, or right, or make sense.  I am simply stating the rules and facts.

Medicare Guidelines for Skilled Nursing Facility

Skilled Nursing Facility Medicare Covered The third requirement for admittance to a skilled nursing facility (SNF) is the treatment can only be provided by a skilled nursing facility.

What this usually means is “full time” or five day a week care.  In other words, the same level of treatment cannot be provided by going to a treatment center by appointment a few times a week.  Only an inpatient skilled nursing facility can provide the level of intense treatment needed for adequate recovery.  This can be a tricky call and where judgments can and are questioned.

Medicare Denial Skilled Nursing Facility

I had a client who had a knee replacement.  Usually a knee replacement, even with does medicare pay for chemotherapy in a skilled nursing facilitycomplications, does not require admittance to a skilled nursing facility (SNF) because physical therapy is something that can be completed by going to the physical therapist’s office and/or doing exercises on your own.  This situation was different.

She was living in a small apartment with lots of furniture.  There was a pet.  The husband was feeble.  While she was not very old, her knee was not recovering at the usual pace.  The doctor recommended skilled nursing care, but Medicare denied the prescription.

The family came to me with questions.  I suggested they explain the situation to the doctor in greater detail and with more urgency.  She was a serious “fall risk” because of her living situation.

Once the idea was emphasized sufficiently in the doctor’s notes to Medicare, Medicare understood that the work that had been done would be undone if she fell at home because of a pet, furniture, and/or feeble husband, etc.  The request was approved.

Skilled nursing is very expensive.  Medicare needs to understand the “medical necessity” of a prescription.  Once the idea is communicated effectively, things can happen.

List of Medicare Approved Skilled Nursing Facilities

The fourth ingredient is that a doctor, or another appropriate medical professional, certifies that the patient needs the type of daily therapy that can only be performed in a skilled nursing facility.  The skilled nursing facility must also be a Medicare-certified skilled nursing facility.  You can go to Medicare.gov to find certified sites and Medicare the star ratings for Skilled Nursing Facilities.

The fifth and final requirement can be confusing.  The skilled nursing care must be for the reason the patient was in the hospital for the three days.

Imagine John goes to the hospital because of a broken hip.  While John was in the hospital, he has a stroke.  The doctor certifieMedicare skilled nursing facility requirementss John for treatment at a skilled nursing facility for the stroke, not the hip issue.  The skilled nursing recommendation does not have to be based on the reason the person was admitted to the hospital, but it does need to be because of something he was treated for during the 3-day hospital stay.

As you can see, Medicare coverage for skilled nursing facilities can be complex.  It’s important to have some understanding so that you know what to expect, or not to expect, when it comes to Medicare coverage of skilled nursing facility care, and how to navigate the processes to your benefit and the benefit of loved ones.  Medicare Part A covers the Skilled Nursing Facility, but the rule must be followed for Skilled Nursing Facility Medicare reimbursement to happen.

 

 

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