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.
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
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.
Know What Medicare A Covers
I have known veterans who only took Medicare A because it was free, and they opted out of Medicare Part B for doctor and outpatient services because it cost something. They thought Medicare A was enough because they could rely on the VA hospital. The VA, however, changes what it will cover or reimburse, depending upon Congress’s budget and who is in the White House. I had another gentleman in my office recently who thought Part B was unnecessary waste of money because he had been healthy all of his life. While Medicare A is good insurance and covers some things, it is very limited if you understand how Part A works. You should never guess about health insurance. You need to know what Medicare A covers and doesn’t cover.
Medicare A was the first Medicare plan in 1965. It covers hospital services. Hospital stays are the most devastating and costly part of health care. Medicare A covers five areas: inpatient hospital stays, blood, skilled nursing facilities, home healthcare, and hospice. It does not cover these services completely. There are deductibles, copayments, coinsurance, and limitations on days of service.
Medicare A Covers 60 Days In the Hospital
The deductible for Medicare A is currently $1,484 for 2021. It has increased with a definite consistency over the years. After the deductible is met, the patient is covered 100% for the next 60 days. After a continuous 60 days as an inpatient in the hospital, the copay is $371 per day for Medicare A coverage. The copay runs from days 61-90. (This cost is assuming you have no other coverage, like a Medicare supplement.)
Lifetime Reserve Days for Medicare
Each Medicare beneficiary has 60 lifetime reserve days for Medicare A coverage. This means the patient may dip into this limited number of days when they go past the 90-day mark. If they use up those 60 days, they are not replaceable. “Lifetime” means lifetime. Even then, the 60 lifetime reserve days for Medicare have a copay of $742 for each day. After the 150 consecutive days, the patient assumes ALL costs. Of course, this is a rare event.
Hospital Stay Coverage Depends on the Day
Staying as an inpatient in a hospital for 60, 90, or 150 days is a very rare event. The more likely occurrence is being admitted to the hospital, discharged, then readmitted for the same thing. That is a number game in itself. Once you are discharged, you need to be out of the hospital for 60 consecutive days. If you are, then the clock starts over again when you are admitted, even if it is for the same reason.
The count starts back up where you left off if you return to the hospital within those initial 60 days. If you left day 15 and are readmitted 30 days later, your second period in the hospital starts with day 16. This is assuming the readmittance is for essentially the same reason. Hospital stay coverage depends on where you fall in the sequence of days.
Does Medicare Cover Blood Transfusions?
Medicare A covers blood and Medicare B covers blood, but in two different circumstances. Medicare does not cover the first three pints of blood. They wait until the fourth pint before they kick in.
If the hospital gets the blood for the transfusion from a blood bank then you may not pay, other than donating blood afterward. Someone else may also donate blood in your name. If the hospital purchases blood, you will either pay or give you the option to donate.
Medicare A Covers Hospice Care
Hospice is for the terminally ill. Terminally ill means the medical prognosis is an expectation of six months or less of life, assuming the illness runs its usual course. Only a Medicare-certified hospice program may take a patient, and the program director, together with the attending physician, determines admittance to the hospice program. Medicare A covers the care totally except for some minor copays for medications.
What hospice provides is PAIN RELIEF. Everything—drugs, medical equipment, nursing, homemaker services—are all designed to reduce pain and maintain some reasonable level of comfort for the dying person. Hospice is generally administered at home.
Some people believe hospice will cover room and board and other housekeeping items in a hospice or nursing home facility. The individual and/or family will bear those costs, not Medicare.
Does Medicare Cover Skilled Nursing Facilities?
Skilled nursing is not nursing home insurance. I get this question almost every week. ‘What happens to me if I have to go to a nursing home?’ If it is not tied to a medically necessary reason for full-time rehabilitation, the nursing home will be on your dime unless you have long-term care insurance.
Skilled nursing care is not custodial care, which means bathing, transporting, feeding, etc. That is what most people imagine when they think of a nursing home. Skilled nursing is something else.
There are five criteria a person must meet to be admitted to the skilled nursing facility that Medicare A covers. The first criteria is a minimum 3-day inpatient hospital stay for a related illness. Then the doctor discharges you to a facility because you cannot continue your treatment on your own. For example, if you need injections or physical therapy.
Second, you must enter the facility within 30 days of dismissal. Third, you can only receive the medically necessary treatment in a skilled nursing facility. You cannot receive the same or similar treatment through home health care or office visits.
Fourth, the skilled nursing facility must be a Medicare-approved facility. Finally, the reason for the stay must be the same reason the patient was in the hospital.
Medicare A covers skilled nursing at zero cost for the first twenty days. However, on days 21-100, the patient pays $185.50 per day unless they have a Medicare supplement or other insurance. Like the hospital stay, there is a formula for starting and stopping the days and how they are counted.
Medicare A Covers Home Health Care
Medicare A covers home health care in much the same way as it covers skilled nursing facilities. There is a list of criteria the patient must meet.
Home health care is like skilled nursing in that it provides skilled care–not custodial. The patient must be certified to receive it. They must be homebound. In other words, they cannot easily go to an office to receive treatment. Medicare will cover home health care completely under Part A for as long as medically necessary and can be verified as necessary. It will be at no cost to the beneficiary.
What Does Medicare Part A Not Cover?
Medicare A does not include Medicare B. Part B is doctor and outpatient procedures, which is the bulk of what most people need. Those are also doctor visits in the hospital.
Medicare Part B does cost something. The Part B premium is currently $148.50 per month per person unless your income is in the top 6%.
Some people who do not take Part B. Maybe they have VA benefits or some other coverage. That can be a mistake.
Medicare A does not cover prescription drugs. Part D covers medications. Part A does not cover dental, vision, hearing, transportation. Those are all medically important services covered in other places and ways.
Medicare Part A Doesn’t Cover All Medical Costs
You paid for Medicare A coverage during your working years. Your payroll taxes included a 1.45% tax for Medicare Part A. It was and is strong protection for seniors against the devastating cost of hospital stays.
Skilled nursing is an important service, and Medicare A comes in to cover it. Home health care is vital for a person’s recovery and getting back to self-sufficiency, and hospice is a tremendously humane ministry Medicare A provides. But alone, Medicare Part A does not cover the medical care that most people need.
I recommend you seriously consider whether you need additional protection. Know your costs and coverage limitations.
Call 402-614-3389 and email us at firstname.lastname@example.org for a free consultation and quote. We will confirm whether you’re covered and if additional protection is right for you.