Home Health CareCategory:

 As people age, the value of good health becomes more important than ever. When you had a bad fall in your 40s, it would take a few weeks to recover. Now, a bad fall may result in a hip injury that takes months of recovery, doctor visits, physical therapy, or even surgery. Some must go to skilled nursing facilities to recover. The contrast is stark. Seniors’ health issues increase in frequency and complexity as they age. According to the National Council on Aging, nearly 95% of older adults have at least one chronic condition, and 3 million adults aged 65 or older are treated in emergency rooms due to fall-related injuries every year. So Medicare beneficiaries ask: How long Will Medicare Pay for nursing home care and home health care? 

Navigating the Complexities of Care: Medicare’s Coverage of Long-Term Care, Skilled Nursing Facilities, and Home Health Care

While preventative care is essential–annual physicals, screenings, and regular tests–and “fall-proofing” your home is critical, you must be prepared financially for the costs associated with extensive medical care if and when that occurs. If a health event puts you in a situation requiring special care or costly in-facility admittance, your first question will probably be, “How am I going to pay for this?”

If you are a Medicare recipient, navigating care in a long-term care facility can be complex and confusing. There are so many different types of care – long-term care (LTC), skilled nursing facility (SNF), and home healthcare (HH) – that it’s hard to know how it all works and how much Medicare is willing to pay for each.

My job is to make that journey a whole lot easier. I’ll break down each of these care types and dive into what Medicare will and won’t cover so that you know your options if you’re faced with a health challenge that requires ongoing care.

The Differences: LTC vs. SNF vs. HH

Understanding the different types of care offerings can feel like a full-time job for aging adults. Terms like assisted living facilities, senior living providers, and skilled nursing facilities are often used interchangeably, but the truth is, there are subtle differences in care and what and how much Medicare pays for the different types of “nursing home care.”

The three essential categories of care for seniors are long-term care (LTC), skilled nursing facilities (SNF), and home healthcare (HH). Understanding what each one does and its purpose can be beneficial when it comes time to finding care for your specific situation.

Long Term Care (LTC)

Long-Term Care facilities are the places we think of as “nursing homes.” A person may go to a long-term care facility for several reasons and lengths of stay. Permanent residents generally go to LTC facilities primarily because they can no longer perform the activities of daily living. 

 The 5 activities of daily living are:

1. Feeding
2. Dressing
3. Personal Hygiene (bathing, brushing teeth, clipping nails, etc.)
4. Continence (control of bladder and bowels)
5. Toileting

If you struggle with any of the above, a Long-Term Care facility may be the right choice for you.

Staffed with caregivers, such as certified nurse assistants, registered nurses, various types of therapists, and doctors–these facilities focus more on providing meals, custodial care like dressing and feeding, and offering social environments for their patients. While also providing health care, the primary focus is custodial care because residents can no longer perform those functions for themselves, their families cannot care for them, and they cannot afford to provide those services in their own homes economically.  

Skilled Nursing Facility (SNF)

Skilled nursing facilities are often in the same physical location as long-term care facilities. The difference comes down to the reason behind your stay. If you need care because of a medical condition – such as a broken hip from a fall, car accident, stroke, or heart attack – then an SNF can provide the medical care you need–intense nursing care, physical therapy, speech pathology. Custodial care, such as feeding or toileting, comes with a stay in the skilled nursing facility, but it is secondary to the primary reason for the stay–intense and daily treatment.

Seniors needing intense physical therapy, speech therapy, occupational therapy, or continuous medical support should reside in Skilled Nursing Facilities until they are recovered, reach a certain level, or plateau. Then you return home, where home healthcare takes over. The nurses, physical & occupational therapists, and speech pathologists come to your home. Eventually, when you have progressed in your recovery and do not need treatment as often, home healthcare stops, and you go to providers’ offices for an appointment.

Home Healthcare (HH)

Home Healthcare providers allow their clients to continue living in the comfort of their homes while providing care. The person still cannot get out and go to appointments easily, so the skilled providers come to you in your home two or three times a week or less, depending upon need. Ideally, in the recovery process, you eventually leave your home and go to their offices to receive treatment until you fully recover. Again, home healthcare does not provide custodial care in the home, except on rare occasions for short periods of time.  

Understanding that Medicare is health insurance.  It covers and pays for doctors, nurses, tests, hospitals–all the things you associate with medical treatment and recovery.  Medicare does not provide custodial care, housekeeping, meal & laundry service, or taxis.

Will Medicare Cover Long-Term Care?

When someone says “long-term care” or “nursing home,” they generally mean the person is residing permanently in a facility because she cannot take care of herself–she cannot perform the 5 activities of daily living. Medicare does not pay for nursing home care. Even when medical necessity requires admittance to a nursing home (skilled nursing facility), the length of stay is capped at 100 days. There are rules around stopping and starting this coverage, coming from a hospital stay, and restarting a stay, but essentially, Medicare will only pay for 100 days per year in a nursing home. And Medicare approval for a stay of that length is rare. Again, Medicare pays for “nursing home” care for purposes of intense but temporary medical treatment.  

Will Medicare Cover Skilled Nursing Facilities?

Medicare provides “Skilled Nursing Facilities” coverage, but patients must qualify based on stringent requirements. Medicare will only cover SNF care if all of the following are true:

1. You are a recipient of Medicare Part A and have days of coverage remaining in your benefit period.
2. A qualifying hospital stay preceded the need for SNF. An inpatient stay of at least 3 consecutive days in the hospital followed by admission into an SNF within 30 days of leaving the hospital is required for coverage.
3. A doctor must have ordered inpatient SNF care based on medical necessity.
4. Your condition requires skilled care daily.
5. You need skilled services for an ongoing condition that was treated during your 3-day hospital stay OR a new condition that started while you were already receiving SNF care for an ongoing condition.
6. The services must be reasonable and necessary for the treatment of your condition.
7. You obtain care through a Medicare-certified SNF.

Even if you qualify, your stay will not last indefinitely.

How Many Days Will Medicare Pay for Skilled Nursing Care?

After qualifying for SNF care, your progress will be closely monitored for the length of your stay, the care you are receiving, and the above requirements to ensure Medicare will continue providing coverage. At a high level, Medicare will cover up to 100 days of SNF coverage within a single benefit period. Again, approval for that length of stay is rare. Medicare wishes to move you to less costly home healthcare as soon as medically possible.  

In those 100 days, Medicare will cover the cost of the following:

• A semi-private room
• Meals
• Skilled nursing care
• Medical social services
• Medications
• Medical supplies and equipment usage
• Ambulance transport when required
• Dietary counseling
• Physical therapy, occupational therapy, and speech-language pathology when required to meet your health goal

It’s important to note that while Medicare will provide coverage for 100 days, you will have to supplement the coverage starting on day 21.

• Days 1 – 20: Medicare will pay the total cost; you pay nothing.
• Days 21 – 100: You pay the daily coinsurance, which can be up to $204 per day in 2024.
• Days 101+: Medicare pays nothing; you incur the total cost of care if you remain.

A detailed breakdown of coverage details can be found in Medicare’s SNF handbook.  Medicare does not pay for nursing home care unless it is tied to a treatment program while you are in residence.  

Will Medicare Cover Home Health Care?

Home healthcare falls under both Medicare Part A and Part B. Home healthcare is defined as part-time or intermittent skilled care when you are “homebound.” Homebound means you cannot leave your home without assistance. Assistance could be using a walker, wheelchair, crutches, or even a cane. You may need special transportation because of your condition. Your doctor may advise you not to leave your home because of your medical condition. These all constitute reasons Medicare will accept for home healthcare.  

The usual services home healthcare provides on a part-time basis are:

• physical therapy
• occupation therapy
• speech-language pathology services
• Injectable osteoporosis drugs
• durable medical equipment

A doctor must certify you need home health care through a face-to-face meeting.  You need part-time or intermittent care, which may be up to 8 hours per day but with a maximum of 28 hours per week.  

Home Healthcare does not include:

• 24-hour adult day care at home
• Meals delivered to the home
• Homemaker services
• Custodial (or personal) care help.

If you do attend adult day care in a facility, you can still qualify for home healthcare.  

Getting the Most from Your Medicare: Which Direction?

There are two ways for you to receive Medicare: Original Medicare or Medicare Advantage.

Original Medicare

Original Medicare is Part A for inpatient hospital stays and Part B for outpatient services and doctor visits. There are no networks for Original Medicare. It is fee-for-service (FFS), which means if the doctor or facility accepts Medicare–accept assignment for Medicare is the proper terminology–then Medicare will reimburse the provider for medically necessary services rendered.  

Original Medicare does not include Part D for prescriptions, and Orignal Medicare has big gaps in coverage. A quarter of people purchase some sort of supplemental insurance policy, such as Medigap, to fill in the gaps in coverage.  

Medicare Advantage/Part C

The other direction is Medicare Advantage (or Part C). These plans are provided by a private insurance company that is Medicare-approved to provide health coverage that is equal to or better than Original Medicare.  

The gaps in coverage are structured differently than Original Medicare. Medicare Advantage plans have a maximum out-of-pocket. Original Medicare does not.  For example, the most popular Medicare Advantage plans in Omaha, Lincoln, and Council Bluffs have a maximum out-of-pocket of less than $4,000. Original Medicare, on the other hand, does not have a maximum. The sky is the limit for your out-of-pocket costs. 

Medicare Advantage is also built on provider networks. The Omaha, Lincoln, Council Bluffs metro area has four healthcare networks: CHI (Catholic Health Initiative), Nebraska Medicine, Methodist Health Systems, and Bryan Hospital. All these networks work with the Medicare Advantage plans in Omaha, Lincoln, and Council Bluffs. Access to providers is a non-issue for us. In other places and with other Medicare Advantage plans, there can be issues and problems, but not here.     

Home healthcare is zero for both Original Medicare and most Medicare Advantage plans.  

Skilled nursing is zero for the first 20 days for both. On the 21st day, Original Medicare has a copay of $204 during the potential 100 days of coverage–again with no cap on expenses for Part B. Medicare Advantage plans have copays of various sizes, but the key is a limit to what you could pay– a maximum out-of-pocket. 

For those who pay the additional premium for the Medigap plan, the skilled nursing facility copay will usually be covered entirely.   

Medicare Part D

Medicare Part D prescription drug plans are another premium. Most Medicare Advantage plans in Omaha, Lincoln, and Council Bluffs include the prescription drug plan and are mostly at zero cost.  

Neither Original Medicare with a Medigap plan nor Medicare Advantage provides long-term care, custodial care, housekeeping, or adult day care. They may cover some of these services as incidental to providing skilled nursing care in a facility or home but for short periods.  

Alternative Ways to Pay for the Care You Need

In 2021, the average cost of long-term care services ranged from $20,280 to $108,405 annually. These prices are exorbitant, and they’re only going up. As you age, the best thing you can do for your health and your wallet is to ensure you have the coverage you can rely on if you need long-term care. Since Medicare doesn’t pay for many long-term care scenarios–“nursing home care”–knowing your other options for coverage is crucial.

Private Pay

Although challenging, some people will pay for their nursing home care from their savings and assets. By dipping into retirement accounts, tapping into assets such as property or investments, or simply saving up over their lifetimes, some seniors pay out-of-pocket for all the care they receive.  This is rare.  

One major benefit to this approach is that LTC facilities often prioritize private pay clients when space is limited. With the looming senior care crisis, this will get even more important in the years to come.

Long-Term Care Insurance

A separate long-term care insurance policy can pay the cost of residing in a long-term care facility. In most scenarios, these policies require that you need help with two or more of the activities of daily living (feeding, dressing, hygiene, continence, and toileting) before they take effect. There are usually elimination periods of 30, 60, 90, and 120 days before a policy will pay. The premiums for these insurance plans are not cheap. As you age, like life insurance, the price goes up and can be beyond the budget of many people. You also need to pass underwriting when you apply for the policy, though it will be guaranteed renewal for the rest of your life, no matter your health, as long as you continue to pay the monthly premium.

Veteran Benefits

If you served in the military, you may qualify for some sort of long-term care benefits from the Department of Veterans Affairs. Eligibility will depend upon length of service, type of service, military-related disabilities, and even income. Then, there may be limited or no facility access in your area. Where there is a facility, availability may be limited in terms of beds. Contact the Department of Veteran Affairs to determine for what you qualify.  Access is very limited in Nebraska.   

Medicaid

Often confused with Medicare, Medicaid is an entirely different health program. It’s partially funded by the federal government but funded and managed by the state.

Medicaid provides low-income seniors with financial help for long-term care. Each state has its own eligibility guidelines, but you’ll need to demonstrate financial need to qualify.

Many times people will tell me that so-in-so is in a “nursing home,” and they pay nothing.  That is because all their assets have been depleted, and they are on county assistance.  Medicaid is paying the bill, and all their assets are gone or will be upon death.  The state takes homes and any other assets to offset the loss to the taxpayer who covers the expense.    

Medicare Does Not Pay for Nursing Home Care: Your Health is in Your Hands

LTC, SNF, and HH are a jungle of terms, regulations, insurance, and costs. It is even confusing for experts. Like figuring out your income tax or finances, consulting an insurance professional will be helpful.  You need someone who knows Medicare, Medicare insurance, the CMS rules and regulations, and possesses years of experience dealing with Medicare.  He can guide you through the maze of Medicare and help you take your health care into your own hands and plan for the best outcome.

You’re in the right place if you’re unsure where to start. Every week, I spend time helping those on Medicare just like you find the right coverage for their needs. At Omaha Insurance Solutions, we can help you figureout the best direction for you, enroll you in Medicare, choose a plan, and get all the T’s cross and I’s dotted on forms and applications. Each year, we will review your needs and the plans available to maximize your Medicare benefits.

Get in touch with us today at 402-614-3389 for a free, no-obligation consultation about your Medicare options.  

 

Medicare 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 Benefits

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 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.

The 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.

Navigating the Complexities: What You Need to Know About Medicare and Home Healthcare Coverage

Are you confused about Medicare and home health care coverage? If so, you’re not alone. Navigating the complexities of these topics can be overwhelming.  It’s essential to understand your options and ensure you receive the care you need.

Does Medicare pay for home health care services?

This article will delve into the ins and outs of Medicare and home healthcare coverage, providing the information you need to make informed decisions. We’ll explore the different types of Medicare plans and how they relate to home healthcare services, eligibility requirements, coverage limitations, and common misconceptions.

Whether you’re a senior seeking assistance or a caregiver supporting a loved one, understanding how long Medicare pays for home health care is crucial. By the end of this article, you’ll clearly understand what options are available and how to navigate the complex healthcare landscape.

Stay tuned to discover everything you need about Medicare and home healthcare coverage. Don’t let the confusion hold you back from accessing the care you deserve.

Different Types of Medicare Coverage

Medicare is a federal health insurance program that covers people over 65 and those with specific disabilities or chronic conditions. There are several types of Medicare plans, each with benefits and limitations. Knowing how long each Medicare plan pays for health care is critical. 

Original Medicare, also known as Medicare Part A and Part B, provides coverage for hospital stays, doctor visits, home healthcare, and some medical equipment. Medicare Part C, also known as Medicare Advantage, is a private insurance option combining Parts A and B, often including additional benefits such as prescription drug coverage and dental care.  Both provide home healthcare coverage, but in specific ways unique to the plans.  

Medicare Part D provides coverage for prescription drugs, while Medicare Supplement plans, also known as Medigap, help cover the costs of out-of-pocket expenses not covered by Original Medicare.

Understanding the differences between these plans is essential because they approach home health care differently.  

Understanding Home Healthcare Services

As the name suggests, home healthcare services provide medical care and support to individuals in their homes. This can include services such as nursing care, physical therapy, and speech-language therapy. Home health care is often a more convenient and cost-effective option than hospital or skilled nursing facility (SNF) care and can provide a higher level of comfort and independence for patients. It is skilled nursing care but provided in the home for those who would not have access to medical care otherwise.

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 back your health and independence again.  

For the chronically ill and disabled, the goal of home health care is to maintain the highest level of ability and health.

Home healthcare services can be provided by a variety of healthcare professionals, including registered nurses, licensed practical nurses, physical therapists, occupational therapists, and speech-language pathologists. A physician typically orders services, and they are covered by Medicare and/or private insurance.

Home health care is not home care. Home care would be custodial services like housekeeping, bathing, feeding, etc. Medicare does not usually provide those types of personal services, strictly speaking. There are exceptions, however. On occasion, Medicare allows for a temporary home health aide to assist in the healing process.  

Some injuries and illnesses may last for a long time. While home health care is a necessary service, the bigger question is: how long does Medicare pay for home healthcare?  

Medicare Eligibility for Home Healthcare Coverage

Individuals must meet specific requirements to be eligible for Medicare home healthcare coverage. First, they must be enrolled in Medicare Part A and/or Part B. Both Medicare Part A and Part B provide home healthcare coverage.  

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. The added benefit is Part B does not require a qualifying hospital stay.

The essential requirements of eligibility and access to Medicare home healthcare services are: homebound, physician certification, and Medicare-certified agency care. 

Homebout, in Medicare terms, means that leaving the home requires a considerable and taxing effort. A physician is the gatekeeper of Medicare home healthcare.  The physician certifies and/or recertifies a patient for access to home healthcare.  Finally, a Medicare-certified agency must provide home healthcare services, not any healthcare provider.    

Medicare Part A Coverage

In contrast, Medicare Part A provides home health care coverage in some situations. A hospital or skilled nursing facility stay triggers Part A. If a person has a three-day inpatient stay at a hospital or has a Medicare-covered Skilled Nursing Facility (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 For Home Healthcare Services 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 services.
• Eighty percent of the Medicare-approved amount is for durable medical equipment.

Medicare covers a wide range of home health care visits, including skilled nursing care, physical therapy, occupational therapy, speech-language pathology, and medical social services. These services are typically provided part-time or intermittently, depending on the individual’s needs.

Medicare also covers specific durable medical equipment and supplies, such as wheelchairs, hospital beds, and oxygen equipment.

However, coverage limitations and restrictions may apply, and it’s essential to understand what services are covered and how much you may be responsible for paying out of pocket. The agencies providing the equipment and supplies can give details of costs.

Limitations and restrictions of Medicare coverage for home health care

While Medicare provides coverage for many home healthcare services, there are limitations and restrictions to be aware of. For example, Medicare typically only covers part-time or intermittent care and may not cover 24-hour or long-term care.

In addition, Medicare may not cover certain services considered custodial care, such as help with bathing, dressing, and eating. Finally, there may be coverage limitations based on the individual’s medical condition.  Some coverage is subject to annual or lifetime caps.

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

Tips for Navigating Medicare and Home Healthcare Coverage

Navigating the complexities of Medicare and home healthcare coverage can be challenging, but several tips help make the process easier. First, it’s important to understand your needs and choose the Medicare plan that best fits them.

Second, work with your healthcare provider to ensure that a Medicare-certified agency orders and provides home healthcare services. 

Finally, read the fine print and understand any coverage limitations or restrictions that may apply. The Medicare-certified agency is well versed in the cover limitations and costs. Be sure to consult with them ahead of time.  

Alternative options for home health care coverage

While Medicare provides coverage for many home health care services, alternative options may be available to better meet your needs. For example, private insurance plans may offer more comprehensive coverage for certain services.  Medicaid is another route for low-income individuals.

Private Home Health Care Insurance Policies

Home health care insurance is typically a private insurance policy purchased ahead of time to assist Medicare in caring for someone receiving home health care. The policy covers activities of daily living in the home, such as bathing, feeding, transportation, and housekeeping. Like any insurance, these alternative options must be purchased before the health issues arise. Many insurance carriers offer a variety of these types of policies.    

In addition, a variety of community-based programs and organizations offer support and assistance to seniors and individuals with disabilities. These programs may include meal delivery, transportation services, and assistance with daily living activities.

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.
• 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.

How Long Does Medicare Pay for Home Health Care?

There is no limit to the length of time that a person can receive home health care services. Once the initial qualifying criteria are 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 a certain amount 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 a physician may recertify a patient.  Provided all eligibility requirements continue, he can recertify an unlimited number.

What Happens When Medicare Stops Paying for Home Health Care?

A home health agency must give a beneficiary a written Home Health Change of Care Notice (HHCCN) when the patient’s plan of care changes because the home health agency decides to reduce or stop providing some or all of the home health services or supplies. Or, the patient’s doctor has changed the orders, which may reduce or stop certain home healthcare services or supplies that Medicare covers.

For example, the doctor changes the care plan from five to three days a week. The agency issues an HHCCN.  The beneficiary receives a notification in writing of the change.

The HHCCN lists the services or supplies that will be changed and gives the beneficiary instructions on what to do if she disagrees. 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 a person’s Medicare-covered services end, 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 contacting the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) to request an expedited appeal.

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

A physician must submit a statement of appeal to the BFCC-QIO.  It says the patient’s health will be jeopardized if care is discontinued. These factors determine how long Medicare pays for home health care. Knowledge of these rules is vital to maximize benefits and avoid costly mistakes.

Importance of understanding Medicare and home health care coverage

Understanding Medicare and home health care coverage is crucial for seniors and individuals with chronic conditions or disabilities. These programs provide access to essential medical care.  They support individuals to maintain their independence and quality of life.

By understanding the different types of Medicare plans, eligibility requirements, coverage limitations, and alternative options, individuals can make informed decisions about their healthcare and ensure they receive the care they need.

Bottomline: Taking Advantage of Medicare and Home Healthcare Benefits

In conclusion, navigating the complexities of Medicare and home healthcare coverage can be challenging, but it’s essential for seniors and individuals with chronic conditions or disabilities. By understanding the different types of Medicare plans, eligibility requirements, coverage

limitations, and alternative options, individuals can make informed decisions about their healthcare and ensure they receive the care they need.

Whether you’re seeking home healthcare services for yourself or a loved one, working with your healthcare provider and understanding the coverage options available is essential. By taking advantage of Medicare and other home healthcare benefits, you can maintain your independence, improve your quality of life, and ensure you receive the care you deserve.

At Omaha Insurance Solutions, we help you understand the many Medicare rules.  We navigate you through the forms and get the care you need.  Call us at 402-614-3389 to speak with an experienced, licensed insurance agent professional.

 

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.

• 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-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 Homebound

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 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.

Durable 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?

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

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.

What Are Skilled Nursing Facilities?

All of us have strong memories of visiting the “old folks’ home.”  Whether grandparents, relatives, or friends, we recall the smells, linoleum, long hallways, and institutional dormitory rooms.  “Old folks’ homes” or nursing homes fall under the category of Skilled Nursing Facilities (SNF).  Medicare covers skilled nursing facilities within limits.

Patients go to the SNF after surgeries to recover, from illnesses to heal, and from injuries to recover and strengthen.  Skilled Nursing Facilities are for temporary treatment, not long term residential care or custodial care, like memory care.  Other facilities, like senior living communities, assisted living, or senior care centers describe other types of facilities that assist seniors.

A skilled nursing facility provides highly skilled professionals, such as occupational therapists, physical therapists, registered nurses, speech therapists.  The advantage of an SNF is these professions are available 24 hours a day for the patients.  The level of care is very high but short term.

Post-Acute & Skill Rehab Services

Skilled Nursing Facilities are institutions that provide post-acute skilled nursing care and rehabilitation services.  People sometimes confuse skilled nursing care with nursing home care because most of the time skill nursing usually takes place in a nursing home location.  Medicare, however, doesn’t pay for “nursing home care”.

Medicare covers skilled nursing facilities within specific parameters.  Nursing home care is for individuals who have reached a point in life when they can no longer perform activities of daily living.  This is referred to as custodial care.  In other words, they cannot bath, feed, and dress themselves.  Medicare will not pay for those services to be provided exclusively.

Skilled Nursing is for after surgery or acute illness, for example, hip surgery for a fractured hip or a stroke.  A skilled nursing facility admits patients for a short period of time after being in the hospital to aid in their healing and/or rehabilitation.  Hospitals are incredibly expensive, and a skilled nursing facility can provide the necessary treatment at a lower cost.

Medicare Criteria For Skilled Nursing Facilities

The tricky part about skilled nursing facilities is admittance.  A skilled nursing facility requires patients to meet certain essential criteria for admittance and for Medicare to pay.  This is the complex checklist:

1. The patient must be admitted to a hospital as an “inpatient” for at least three consecutive days, not including the day of dismissal. She can’t be in the hospital for “observation” for it to count for Medicare to pay.
2. Medicare mandates patient admittance to the skilled nursing facility within 30 days of discharge from the hospital. If problems arise later—past 30 days—the patient cannot go to the skilled nursing facility and have Medicare pay for it.
3. Only a skilled nursing facility can provide the type of care necessary for the patient’s recovery.   A skilled nursing facility would provide intense physical therapy for a hip injury or occupational therapy after a stroke. Going to the physical therapist’s office a couple of times a week would not be sufficient in those cases.
4. A doctor, or appropriate medical professional, must certify that skilled nursing care is required for recovery.
5. The patient must be treated for the same condition for which she was in the hospital.

There are nuances and exceptions to some of these rules.  The list gives you a good idea about how skilled nursing fits into your Medicare health insurance.  The Omaha, NE area has many quality Medicare certified facilities, and  You can find them on the Medicare.gov website.