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.
- A physician must certify home health care is necessary.
- The home health care provider must be a Medicare-approved organization.
- The patient must need at least one of the following: skilled nursing care, physical therapy, occupational therapy, or speech therapy.
- 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.
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.
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
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 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
Medicare 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.
The chances are you or someone in your family will require skilled nursing care because of a serious injury, stroke, or surgery. Twenty-five percent of skilled nursing stays are less than three months. Many, however, are longer. Nursing home care costs vary from state to state and location to location. The questions my clients ask are: how long does Medicare pay for skilled nursing care?
Skilled Nursing Care Costs Are High
Depending upon the state in which you reside, the daily costs associated with nursing home care vary widely between $140 and $771 per day for a semi-private room in 2017. The average cost was $235 per day for a semi-private room. Multiplying that out the monthly cost associated with skilled nursing care ran anywhere between $4,258 and $23,451 per month for a semi-private room, with the average being closer to $7,148 each month for a semi-private room. For most people, those are prohibitive costs!
How Much Skilled Nursing Does Medicare Pay For?
Many of my clients will call when faced with the possibility of going into a skilled nursing facility. Illness is scary enough. You don’t want to worry about overwhelming medical bills. My people want to know they’re covered. They want to know how much skilled nursing does Medicare pay for. Do Medicare Advantage plans cover skilled nursing facilities? Do Medicare Supplements cover skilled nursing facilities? So, the big question is: who pays?
Medicare Skill Nursing Benefit Period Is 100-Days
So, how many days does Medicare cover skilled nursing facility care? The Medicare Skilled Nursing Facility (SNF) benefit period, or “Spell of care,” is 100 days. The benefit period ends when the patient leaves the SNF for 3o days, and a new 100 day benefit period is available after 60 days.
Skilled Nursing Facility’s Legal Obligations
When a patient leaves a hospital and moves to a nursing home that provides Medicare coverage, the nursing home must give the patient written notice of whether the nursing home believes that the patient requires a skilled level of care and thus merits Medicare coverage. Even in cases where the SNF initially treats the patient as a Medicare recipient, after two or more weeks, often, the SNF will determine that the patient no longer needs a skilled level of care and will issue a “Notice of Non-Coverage” terminating the Medicare coverage.
Whether the non-coverage determination is made on entering the SNF or after a period of treatment, the patient can submit or not to Medicare. The patient (or his or her representative) should always ask for the bill to be submitted. This requires the nursing home to submit the patient’s medical records for review to the fiscal intermediary, an insurance company hired by Medicare, which reviews the facility’s determination. The review costs the patient nothing and may result in more Medicare coverage. While the review is being conducted, the patient is not obligated to pay the nursing home. However, if the appeal is denied, the patient will owe the facility retroactively for the period under review.
If the fiscal intermediary agrees with the nursing home that the patient no longer requires a skilled level of care, the next level of appeal is to an Administrative Law Judge. This appeal can take a year and involves hiring a lawyer. It should be pursued only if, after reviewing the patient’s medical records, the lawyer believes that the patient was receiving a skilled level of care that should have been covered by Medicare. If you are turned down at this appeal level, there are subsequent appeals to the Appeals Council in Washington, and then to federal court.
Day 101 You Pay
If you need more than 100 days of SNF care in a benefit period, how many days will Medicare pay for skilled nursing care? Nothing. SNF is meant to be short term. You will need to pay out of pocket if your care ends because you are run out of days. The SNF is not required to provide written notice. It is important that you or a caregiver keep track of how many days you spend in a SNF to avoid unexpected costs after Medicare coverage ends.
How Else to Pay For Skilled Nursing Care
If you are receiving medically necessary physical, occupational, or speech therapy, Medicare may continue to cover those skilled therapy services even when you have used up your SNF days in a benefit period, but Medicare will not pay for your room and board, meaning you may face high costs.
Medicare does not cover long term care or custodial care. You may wish to move to a home health care situation at that point. Medicare pays for home health care, and the costs are much less. If you have long-term care insurance, it may cover your SNF stay after your Medicare coverage ends. If your income is low enough, you may be eligible for Medicaid to cover the cost of your stay.
Unlimited Skilled Nursing Benefit Periods
Once you are out of skilled nursing for 60 days, your SNF benefit period ends, but you may become eligible again for another SNF benefit period after a qualifying hospital stay of 3-days. There is no limit on the number of benefit periods available to a Medicare beneficiary as long as the Medicare requirements are met.
In other words, a person could potentially keep going into Medicare covered skilled nursing care every 100 days after a 60-day break as long as it is preceded by a qualifying hospital stay of 3-days. While repeat 100 day stays in a skilled nursing facility are not likely, that does give an idea of the level of incredible care available to a Medicare beneficiary.
NO Insurance: $176 Per Day
Medicare Supplements and Medicare Advantage plans pick up large portions of the 100-benefit period. The amount covered depends on the type of Medicare Supplement plan and Advantage plan. If the patients has neither, just Original Medicare, she is responsible for 21-100 days. The per day cost is currently $176 (2020).
30 Or 60 Days
An important note on the number of days out of a Skilled Nursing Facility approved stay. If a patient has left the SNF for 30-days or less, she may return without a 3-day inpatient hospital stay to initial the stay, but the 100-day count continues from where it left off. If the patient has been out of the SNF for 60-days for less, but more than 30-days, she will need another 3-day hospital stay for Medicare to pay for the time in the Skilled Nursing Facility. And the 100-day count continues from where it left off. After 60 consecutive days without SNF care, a new benefit may begin. There is no limit to the number of benefit periods.
Let’s layout some common scenarios. You might need your calculator or at least your fingers and toes to keep track.
Imagine David is in the hospital for 4 days because of a stroke. He is then admitted to a skilled nursing facility for 20 days. Dave leaves the skilled nursing facility for 28 days, but he has a complication. Dave falls going to the bathroom. The doctor readmitted him into the nursing home. He is within the 30-day window. No problem. Medicare will pay for that.
If, however, David was out of the nursing home 31 days, and he fell, he would need another 3-day stay in the hospital to be readmitted to the skilled nursing facility so Medicare would pay. Dave’s doctor may or may not be able to get him re-admitted to the hospital based upon his medical condition.
Skilled Nursing Facilities (SNF) are incredibly expensive. How long does Medicare pay for Skilled Nursing Care? Medicare does cover a 100-day benefit period. Medicare Supplements and Medicare Advantage plans cover large portions of the stay, depending on the plan. The cost, however, starting day 21 is $176 per day to patients without any additional coverage. The 100-day benefit period has very strict rules when it begins and ends. There are rules to which you need to be attentive to avoid unexpected and large bills, and it is worth talking with your insurance agent to make sure you have the maximum amount of coverage you can afford.
My Mother’s Life Expectancy
The doctors diagnosed my mother with ovarian cancer in 2012. I was living in Kansas at the time. I wasn’t able to go on doctor visits with her. My brother, Paul, was taking care of my mom. I would get information about her situation, but it was spotty. My mother was definitely ‘I’m in charge’-type person. Phyllis determined the flow of information, and it was sparse.
Talking with your mother about her health when her mortality is so tightly fixed to it is hard. Looking back now, I was a coward. I should have been more direct. I didn’t realize the seriousness of her situation until much later. She didn’t speak of her death, I assumed, because she didn’t want to worry us though I am sure she was struggling with her own denial.
At the end of 2012, the doctors said there was nothing more to be done. I don’t think I fully grasped what that meant at the time. I also did not anticipate how quickly time would slip away from that moment onward. I’m sure my mother was scared, but she didn’t let on. I stupidly didn’t realize the magnitude of the moment and how she was probably feeling. My own feelings and denial fogged the situation.
My mother was admitted to hospice care (Medicare Hospice Benefits Booklet).
Medicare Hospice Benefit
Hospice care is a benefit under Medicare Part A. To be eligible to elect
hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered to be terminally ill if the
medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course. Only care provided by (or under arrangements made by) a Medicare-certified hospice is covered under the Medicare hospice benefit.
The hospice admits a patient only on the recommendation of the medical director in
consultation with, or with input from, the patient’s attending physician.
Mom’s Terminal Illness
Nature, in its less than glorious side, took its course rapidly. My mother’s health deteriorated in a few short weeks.
Cancer is a painful disease. The health care personnel gave her various pain killers, but even as they did so, we all insanely talked about not wishing to cause addiction. The pain had its own mind. At various times, my mother’s suffering would be such that she needed to go to the hospital. There the doctors could administer intravenous medications that were faster acting and could stabilize her level of pain.
During the last visit, it became clear that we could not take care of her at home. My father, John Grimmond–who would pass away six months later–was not physically able to care for our mother. I was in Kansas, my other brother, Tom, was in Sioux Falls, and Paul was in Omaha but busy with career and family. My mother needed around-the-clock care. We asked ‘does Medicare pay for hospice in a skilled nursing facility?’ Medicare pays for hospice in a skilled nursing facility, but Medicare does not strictly pay for custodial care. That is, it will not pay for bathing, feeding, going to the toilet, etc.
How To Help Mom With Medicare On Hospice
The staff at the hospital initially told us that our mother needed to go to a Skilled Nursing Facility (SNF) because they recognized she required more care than we could provide. They informed us that Medicare would provide and pay for hospice care in the Skilled Nursing Facility, but the cost of room and board and custodial nursing care would not be covered, and they were correct.
The fortunate occurrence, however, was the intravenous nature of her pain killers triggered a reason for skilled nursing care. Medicare does cover skilled nursing care after a qualifying hospital stay of 3-days or more. Intravenous medication administration requires skilled nursing care. A home health care nurse showing up a couple of times at home would not be adequate to the task. Also, she needed physical therapy to improve her strength after the reaction to the pain. Those were sufficient reasons for Medicare to cover her stay in the skilled nursing facility (SNF) and to pay for even the room and board.
Does Medicare Pay For Skilled Nursing Care During Hospice?
Does Medicare pay for hospice care in a skilled nursing facility? Strictly speaking, Medicare does not pay for skilled nursing care because someone is in hospice, but many times there are other triggering events that cause Medicare to cover skilled nursing care. For example, someone who is in hospice falls and breaks a hip. That situation would justify skilled nursing care. A person develops an infection or pneumonia that results in hospitalization. The patient is transferred to a skilled nursing facility to continue the care. In those ways, skilled nursing and the custodial care that accompanies it are available.
Burying a mother is one of those milestone events in our lives. While dealing with all the emotional, spiritual, financial challenges that accompanied that moment, health care cost was not a burden to my family and me. Medicare and my mother’s Medicare plan took excellent care of her and us. I am grateful for such a wonderful program and the insurance that worked with Medicare.
People constantly ask me, ‘What should I do about Medicare?’ They are overwhelmed with all the brochures from insurance companies. They look through the 162 pages of the Official Medicare Handbook and are further confused. Some go to the Medicare.gov website, and are confounded in attempts to navigate through the endless ocean of information. They simply ask in bewilderment, “What does everyone else do?’ A huge number of people choose a Medicare supplement, or Medigap plan, as the solution, but more of an answer is needed than just ‘everyone is doing it.’ Some thoughtful consideration is required.
Part A Deductible
Medicare is a generous health plan. It covers a majority of the hospital and doctor costs, but there is some important exposure to be aware of. Medicare Part A covers the hospital, but only after you pay the deductible of $1,288. That deductible is not an annual deductible. It is per event within a 60 day period. While you would have to be very unlucky, very sick, or both, you could pay that deductible an endless number of times. That is your exposure.
Part B Co-Insurance
Medicare Part B covers 80% of the doctor and outpatient procedures. While that is quite generous, 20% of a big number is still a big number. Heart attacks, strokes, cancer treatment can run into the hundreds of thousands of dollars. Twenty percent of a $200,000 bill is $40,000. Most people would find that beyond the family budget.
And with Part A & B, there is NO maximum-out-of-pocket (MOOP). In other words, you continue to pay as the bills roll in. You do not stop paying on deductibles and co-insurance if all you have is Original Medicare without anything else.
So comes the questions from clients: ‘What should I do about Medicare?’ Medicare supplements or Medigap plans fill in those gaps in Medicare. They cover the hospital deductibles and 20% co-insurance for doctor and outpatient use. Depending on how much you wish to cover, the Medigap plan can cover everything 100%, most of everything, or a potion. You choose. There are ten plans available.
12,200,000 Satisfied Medigap Clients
The fact that 22% of people on Medicare choose a supplement and stay on a supplement for 20-30 years tells you the level of satisfaction. There are currently 55,200,000 Medicare beneficiaries. Of that number 12,200,000 chose a supplement. That number grows each year: 9.7 million in 2010 to 12.2 million in 2015. The key number is that 9 out of 10 Medigap beneficiaries say that they are satisfied with their coverage and keep their coverage. Med Sup Conference Stats
While Medicare is a wonderful health insurance program for seniors, it doesn’t cover everything. You still have exposure to significant financial loss if you only have Medicare alone.
One of the things that holds people back from purchasing a Medicare supplement is that they don’t know. That is, they don’t investigate what Medigap plans are, what the costs are, how much or little they cover. It is simple as making a phone call 402-614-3389. A quote will not cost you anything, but you will have some real, solid information for your decision making process. Take a couple minutes, answer a few questions, and you will be surprised how easily you can find out what you should do about your Medicare @ OmahaInsuranceSolutions.com.