Finding a Medicare advisor in Omaha, NE, is not difficult. If you are turning 65, marketing companies sell your contact information, including birthday and phone numbers, to insurance agents. Lead companies are mailing you business reply cards (BRC) in hope that you will fill them out and mail them back in. Direct mail marketing companies are sending you postcards, flyers, and brochures because they want you to call their 800-Medicare number. Joe Namath and Jimmy J.J. Walker are on an endless loop of commercials coming into your living room telling you about the unbelievable Medicare benefits you do not qualify for. Dynomite!
You will have to contact the FBI witness protection program to avoid the onslaught leveled against you as you approach Medicare eligibility!
Just Having An Insurance License Does Not Make You A Medicare Advisor
As you age into Medicare, an army is coming after you–an army of insurance agents. Some insurance agents, like me, have been around for a while. I earned my Nebraska & Iowa insurance licenses in 2003. Other agents just get their license for the Medicare Annual Election Period (AEP) when Medicare beneficiaries can change their Medicare plans. During those seven weeks of Medicare Annual Election Period AEP (Oct 15th–Dec 7th)–sometimes called “Open Enrollment”—Medicare insurance agents in Omaha, NE, are looking to make some money. They want to get new Medicare clients who are looking to change their Medicare plans.
People, however, are trying to find a Medicare advisor in Omaha, Ne, who is knowledgeable, competent, and trustworthy.
What Does It Take To Become A Medicare Insurance Agent in Nebraska?
A Nebraska insurance license only means that you passed the licensing test and paid the $50 licensing fee. It doesn’t tell you how many times the person took the test to finally pass. It doesn’t tell you her score. You cannot even determine how long the person has been licensed, though you can find out their license number on the Nebraska Department of Insurance website.
While doctors, lawyers, real estate agents, and even hairdressers go through a lengthy and difficult training and testing process, insurance agents for Medicare do not. I do not say this with any sort of pride, but as a matter of fact. Many of my fellow Medicare agents in Omaha, NE, have little or no training, are doing this as a temporary part-time gig, and/or will probably let their license drop at the end of the year.
Baby Boomers Increased The Demand For Medicare Advisors
Medicare health insurance is a federal program that began in 1965. The government created it because most insurance companies did not offer affordable health insurance to seniors. Congress intervened to create a program to protect seniors who were going bankrupt handling healthcare as the American population was living significantly longer in large numbers by the 1960s.
Insurance companies quickly developed insurance products to supplement Medicare where it was lacking. Insurance agents started selling these Medicare supplements. As the baby boomers started aging into Medicare, the demand exploded. There was more demand than what insurance companies and agencies could handle, so they began mass recruiting to find people to sell Medicare supplements. Recruiters promised the usual things to attract large numbers of people–huge sums of money and easy work.
The sales pitch works because each year, thousands of people get their insurance licenses and become Medicare advisors in Omaha, NE, but quickly they find the work is not easy and they do not become rich overnight. Consequently, after they sell to a few friends and relatives, they let their license lapse. The people they signed up then lose their agent.
The Fallout from Poor Medicare Advisors
The consequence is Medicare beneficiaries are left on their own with an insurance product they probably do not understand in a health insurance program that is as foreign as a foreign language. The agent-less persons are now older. Their needs and circumstances are probably changed, and their income is even more limited. It is a bad situation.
While Medicare is not rocket science and I am not a brain surgeon, Medicare and Medicare insurance products have a certain level of complexity. A person needs a knowledgeable advisor to help them avoid pitfalls and maximize their benefits because Medicare and insurance products are always changing.
Independent Medicare Advisors in Omaha, NE
We are independent Medicare advisors in Omaha, NE. That means we do not work for an insurance company. We are not captive to an insurance company restricted to selling only one company or brand. We offer a large variety of companies in Nebraska and Iowa–the big names and the small. They all pay us the same commission, so there is no incentive to offer one company over the other. We are Omaha, Nebraska, Medicare insurance brokers, so we look for the best deal for our clients.
How to Pick a Good Medicare Insurance Agent in Omaha, NE
First, we offer both Medicare Supplements and Medicare Advantage. These are both great options for those whom they fit. Our goal is to educate you on Medicare. The official Medicare handbook, Medicare & You, is over 120 pages of incredibly dull reading. We make it simple and understandable.
Secondly, we show you the actual Medigap and Medicare Advantage plans. Our software pulls together the policies and prices in nice neat rows and columns so you can compare and contrast. You can see the plans on one big four-foot computer screen, and we print out the quotes on one sheet of paper you can take with you.
From my experience, people come to us with separate quotes from various companies and a number of different agents. The mess of papers adds to your confusion. We pull the data up and let you see all the copays, co-insurance, maximum out-of-pocket, and premiums. It is only when you can look at them side-by-side on one computer screen and sheet of paper you can really see and compare.
We print out the quotes so you can take the material home with you. There shouldn’t be any pressure to decide or buy ‘right now.’ Picking a Medicare plan should not be a rush.
Finally, we find out about you and how you wish to manage your healthcare needs. Everyone is unique in how they wish to handle healthcare. Some of that has to do with your personality. Other reasons are your health. Your budget is an important determining factor. We work with you to see what fits you and is most comfortable for you.
Find A Medicare Advisor in Omaha, NE
You will be on Medicare hopefully for a long time. You want your Medicare advisor in Omaha, NE, to walk with you during that time to help you adjust and change as needs and times change. This is an important relationship for the long haul. Give us a call and find out how we help 402-614-3389.
When people talk about Medicare Part C or Medicare Advantage insurance plans in Omaha, Nebraska, they are usually making a comparison. The comparison is generally to Original Medicare and a Medicare Supplement with Part D. These are the two main ways most people get their Medicare. These two ways are very different, and I don’t believe it is really possible to make a legitimate comparison. But, as we used to say as kids, everyone does it. So let’s do it.
Medicare Advantage Insurance Plans in Omaha Nebraska vs. Medigap
The principal reason I don’t believe you can compare Medicare Supplements to Medicare Advantage is that Medicare Supplements are the same across the country. A Plan G in Arizona is the same as a Plan G in Maine. Medicare Advantage programs, however, are different from state to state and even from county to county. So I will compare Medicare Advantage insurance plans in Omaha, Nebraska, to Medicare Supplements here.
Low-Cost Medicare Advantage Plans in Nebraska
Price is the main attraction for many of my thousands of clients to Nebraska Medicare Advantage (MA plan). Most of the plans have no premium. A couple of them have minimal premiums, like $19, but the majority is zero. Clients like that, but they especially like the price in comparison to Medigap monthly premiums. A Plan G in this area for a male is approximately $150 per month on the low end. A drug plan could be $20 more or less. The simple math for a Plan G and a Part D prescription drug plan, including the Part B deductible, is around $2,200 a year. Most people do not spend anything close to that in annual copays on a MA plan.
Yes, one year or maybe two years, you might spend more than that on a Medicare Advantage plan in Nebraska, but over five, ten, fifteen years, most clients will pay out far less than the monthly Medigap premium that is constantly increasing with age and rate increases.
Medicare beneficiaries constantly compare notes, which is an excellent source of referrals for me. I had a young lady come in recently. Her son, a client, brought her to the office to save money on her Medigap policy. She was 96 and paid $500+ per month for her Medicare Supplement. We submitted an application for a lower-cost Medigap policy since she was in good health. She passed, and we saved her over $3,000 a year. The cost of many Medigap policies can get entirely out of hand.
An agent should have been helping her keep her costs down all this time, but regardless, people see the price of supplements. They look at the Medicare Advantage insurance plan in Omaha, Nebraska, with no premium and very minimal copays, and they ask themselves, ‘Why?’
Why Pay Thousands of Dollars in Medigap Premium Each Year?
In the last analysis for most people, Medicare Advantage will result in less out-of-pocket costs than Original Medicare and a supplement and Part D plan in the long run. In the short run, most people will pay less with a Medicare Advantage plan. The general population recognizes this, which is why the continuous increase in enrollments throughout the country into Medicare Advantage plans.
Medicare Advantage Insurance Plans in Omaha, Nebraska, Maximum Out-of-Pocket
The downside of Medicare Advantage plans is when someone is seriously ill. One of my clients, a high school math teacher, developed leukemia, and the treatment was costly. The illness and treatment began in the fall. He hit his maximum out-of-pocket at that time, which was $4,900. The following year the treatments continued, and he reached the maximum out-of-pocket again. Dan was not happy about being on a Medicare Advantage plan. His cancer appeared a year after he started on the plan.
We discussed switching to a supplement once his cancer went into remission. I waited two years and called Dan to do a supplement. Medigap plans usually have a two year gap required of being cancer-free. When we talked, he had decided to stay with the Medicare Advantage plan. He saw how over time, it saved him money. It must have been the math teacher in him. I was surprised, and I reminded him how upset he was a couple of years ago. He assured me that he was ok remaining on the plan, and he reminded me how emotional cancer can be.
I always remind people the maximum out of pocket is an actual number. The chances of one hitting that number at some point are real. I highly encourage clients to save the money they would otherwise spend on monthly premiums to offset the cost of copays and a challenging year.
Doctor Networks In Medicare Advantage Programs Omaha, Nebraska
Yesterday, I met with a lady who told me, “I don’t want a plan that tells me what doctors to see.” When I hear that phrase, I know they have listened to a Medicare Supplement advertisement or someone on YouTube deriding the evils of Medicare Advantage.
Medicare Advantage plans have networks just like the employer health plans most people were on most of their lives. Insurance companies develop networks for the purpose of keeping prices down.
As I said earlier, Medicare Advantage plans are local plans. They design the Medicare Advantage plan around a particular area, and the networks are no different. In the Omaha Metro area, which includes Lincoln, Bellevue, and Council Bluffs and all the small towns surrounding, there are three networks. Virtually every health professional in the area is associated with one or all of these networks. There are a couple of independent hospitals, but they also affiliate with the local Medicare Advantage plans in Omaha, Nebraska. In our area, there is absolutely no issue, and the networks and plans are going nowhere. These local plans and networks have been working together for years.
In other places, like Kansas City, where I have clients, the Medicare Advantage network criticism has some merit. I carefully check and double-check doctors and hospitals in that area because it is not as homogeneous as the Omaha Metro area. Of course, the Kansas City Metro is much more significant in terms of population and area. With 35 Medicare Advantage plans in Kansas Metro, finding the doctors and hospitals you prefer is not hard.
National Networks And PPO Plans
But the network issue is actually becoming irrelevant as Medicare Advantage plans develop and grow. A larger and larger majority of doctors and medical facilities are becoming part of the MA network systems, and many of the insurance companies that offer Medicare Advantage plans also have national networks. With some plans, even HMO plans, clients may access doctors and hospitals across the country and pay in-network prices.
For a while now, the insurance companies have included PPO (Preferred Provider Organization) plans. With a PPO plan, you have the in-network providers, like an HMO. Those doctors and medical facilities are at the lower in-network copays. The doctors and medical facilities not in-network cost a little more and have a higher total maximum out-of-pocket. As long as the doctor and hospital take Original Medicare, they will accept the PPO plan. Either way, this issue is becoming more and more a non-issue.
I also try to bring people back to reality. I ask, ‘How many times in your lifetime or your family have you left your area to go to a doctor or hospital over a hundred miles away?’ The reality for most people is zero. Sometimes the emotional sales language of the Medigap only insurance agents can cause a disconnect.
Medicare Advantage plans manage care like your employer’s health plans. The insurance company monitors the treatment you receive to make sure it is within customary standards of treatment. If not, the insurance company will question the requests. So the insurance company must approve a majority of the procedures before they are performed.
Original Medicare does not manage care in the same way. Providers must meet the same standard of care, but there is no thorough review or preapproval process.
Ironically in the same turn, Medicare hammers hard on the subject of Medicare fraud. CMS (Center For Medicare & Medicaid Services) encourages Medicare beneficiaries or whistle-blowers to report waste, fraud, and abuse, but they do not have the same preapproval process that would significantly reduce waste, fraud, and abuse.
How To Stop Waste, Fraud, & Abuse?
Fraud is fairly self-explanatory. It is financial gain through deception, but waste and abuse are what the insurance companies try to avoid through their managed care practices. Doctors will sometimes overprescribe. They recommend treatments that are more–and consequently more expensive–than is customary and necessary. For example, the doctor recommends an MRI for a shoulder problem instead of physical therapy to handle the issue. You might say to yourself that it’s up to the doctor, but there are customary and standard procedures of diagnosis and treatment. What would prevent a doctor from ordering a whole list of tests and procedures because he wants to be extra special careful.
An MRI is much more expensive than a couple of visits to the physical therapist that may solve the problem. If the physical therapist concludes that more than a few treatments are required to repair the issue or the treatment does not work, then the treatment moves to the next level, which may be getting an MRI at that point.
Some people may like that more liberal approach to health care. Original Medicare and Medigap policies will be a good fit. For those who are not concerned about the insurance company managing the care, as you experienced during your working years, then managed care or MA plans are a good fit.
Dental, Vision, Hearing, & More In Medicare Advantage Plans In Omaha, NE
The feature that is a big attraction for Medicare Advantage plans is the additional benefits, such as dental, vision, fitness membership, etc. Original Medicare does not cover dental or vision in the form of eyeglasses. Those are benefits seniors want and do not want to pay an additional premium for a dental & vision plan.
The Medicare Advantage insurance plans in Omaha, Nebraska have those benefits in varying amounts–teeth cleanings, $1,500 toward crowns & root canals, $300 for eyeglasses. The fitness memberships are attractive because it not only saves a member $500+ in gym fees annually, but it also gives them the flexibility to go to multiple gyms.
Part C or Medicare Advantage reduces the monthly cost for health coverage, provides broad access to doctors and hospitals, and adds additional benefits at little or no cost. For Medicare Advantage insurance plans in Omaha, Nebraska, the disadvantages that are problems in other places are not really issues here.
For those who do not wish to be on the hook for medical bills that may exceed $3,000 or $4,000 in a given year, MA plans may not be the best fit. If there is some concern that an insurance company may have more control over the management of their health care than Medicare itself, Original Medicare may be a better choice.
So, What Questions Should You Ask Your Medicare Insurance Agent?
What Is Medicare Advantage?
Sometimes there is confusion about Medicare Part C or Medicare Advantage insurance plans in Omaha, Nebraska. I have heard doctors’ offices call it “Medicare replacement plans” or “it is not Medicare.” So when asking what questions to ask your Medicare insurance agent, the definition of Medicare Advantage should be top of the list.
The key is in the name–Medicare Part C, like Medicare Part A and Part B. The Official Medicare.gov website says:”Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. They are sometimes called “Part C” or “MA Plans,” which are offered by Medicare-approved private companies that must follow the rules set by Medicare.”
Medicare mandates what the private insurance companies cover and even how they cover patients’ needs. The monitoring is incredible. This is definitely a question you should ask your Medicare insurance agent.
When I moved into my neighborhood, I got to know my next-door neighbor. He was a partner in a large public accounting firm in Omaha. When he saw my license plate–it says “Medigap”–he asked me to guess who his most prominent client was.
CMS (Center for Medicare and Medicare Services) administers Medicare. CMS is an enormous bureaucracy, but they do not have the capability to monitor something as complex and large as many insurance companies, so they hire auditors. My neighbor’s biggest client is Medicare.
His firm and many other accounting firms audit the financial and billing records of the insurance companies offering Medicare Advantage because Medicare is not directly administering the insurance programs like they administer Medicare Part A and Part B. Small world.
Even though private insurance companies design and administer the Medicare Advantage plans. “Medicare Advantage Plans must cover all of the services that Original Medicare covers,” as it says on Medicare.gov. Confused? These are questions you should ask your Medicare Insurance agent.
What Other Questions Should You Ask Your Medicare Insurance Agent?
Why Medicare Advantage?
In the early 1970s, Congress was trying to figure out how to keep the costs down for Medicare. They imagined involving private insurance companies and creating an atmosphere of competition. Over the decades, the program developed into what is now Medicare Part C or Medicare Advantage.
The number of Medicare beneficiaries on Medicare Advantage is over 40% and growing each year as the plan strengthens. The plans improve health outcomes from beneficiaries, more benefits, and lower costs to Medicare.
How Does Medicare Advantage Work?
How Medicare Advantage works is a question that you should ask your Medicare insurance agent. CMS, in effect, hired a private insurance company to develop a Medicare plan. The plan gives the same coverage as Medicare Part A and Part B. CMS pays the insurance companies an amount based upon the number of clients, ages, services, and outcomes. The formulas to determine payment have become increasingly complex as CMS and the insurance companies try to devise a system that motivates healthcare workers, institutions, and insurance companies to curtail costs and improve health outcomes.
You Should Ask Your Medicare Insurance Agent How To Compare Medicare Advantage To Medigap
Each type of Medicare plan is structured the same from place to place. The plans, however, vary in costs. High population centers like cities will have very rich plans compared to isolated rural areas.
They are not like Medigap plans that work with Medicare Part A and Part B, which are universally the same from one part of the US to the next. The population has absolutely no effect on Part A and Part B. The Medigap plans maybe even less in rural areas because older populations tend to move to higher population areas around doctors and hospitals. Thus Medigap claims in rural areas are fewer and smaller.
You cannot compare Medicare Advantage to Medigap in any way that is fair. They have two separate and distinct delivery systems for health care. Those who do attempt comparisons are usually building straw men to know down to serve their purposes.
One of the Most Important Questions to Ask Your Medicare Insurance Agent:
The first metric I like to consider is the maximum out-of-pocket. The maximum out-of-pocket (MOOP) is how much you potentially could spend out of your pocket while on that particular health plan in one year. During your working years, your employer’s health plan had a MOOP.
Many people confuse MOOP with a deductible. A deductible is the amount of money you pay before the plan begins to cover medical costs. For example, you have a $2,000 deductible. You go to the emergency room, and the bill is $20,000. You pay the first $2,000 upfront.
Then, you pay a coinsurance of 20% on the next $18,000, which would be $3,600 ($18,000 x 20% = $3,600).
This is how the maximum out-of-pocket (MOOP) works. The $2,000 deductible + $3,600 coinsurance = $5,600. If the MOOP is $6,000, you would pay $5,600. If the MOOP was $5,000, you would pay $5,000. This information is crucial, and it should definitely be part of the questions that you ask of your Medicare insurance agent.
I see the maximum out-of-pocket as the most important number because that is your potential maximum risk, which is why it’s so important to ask questions of your Medicare insurance agent about it. While it is highly unlikely that you will arrive at the maximum each year or any given year, there is some probability. Because of that chance, you should be prepared to cover that expense because you are contractually obliged.
If you have two years back-to-back of expense–imagine chemo and radiation for cancer over a year’s time–you could conceivably have two consecutive years together when you reach your MOOP both years. While the probability of hitting that maximum is very low, the possibility is always there.
You can either cover that risk by purchasing a Medigap policy instead of a Medicare Advantage plan and pay the monthly premium or save that amount each month until you have reserves equal to or greater than your MOOP.
When looking at Medicare Advantage plans in Omaha, Nebraska, the first number I look at is your maximum risk–the maximum out-of-pocket (MOOP).
What Other Questions Should You Ask Your Medicare Insurance Agent?
Medicare Part C Many Times Include Prescription Drug Coverage
Most Medicare Advantage also includes the Part D prescription drug plan, especially Medicare Advantage Plans in Omaha, Nebraska. I would run your medications through the Medicare.gov plan finder before going any further in plan selection. Many times I thought I had the best plan picked out, and then I come to find certain medications for that person or not covered. Or the cost of the medications is significantly higher than on other plans. Check the medications before doing anything else.
While you can ask for drug exceptions from a plan, I would absolutely not go into a new plan with that expectation. Ask your Medicare insurance agent to make sure all of the medications are covered and covered at a reasonable rate compared to the other plans in the area.
They Tell You What Doctor to Go See
Many times I will hear someone say, ‘Medicare Advantage plans tell you what doctors to see.’ When I hear that, I know that person only sells Medigap policies. Here’s a prime example of when you need a Medicare insurance agent to ask questions from.
Networks are important. The Medicare Advantage insurance plans in Omaha Nebraska are embedded in the three hospital network systems here.
You, of course, want to go to the medical professionals with whom you already have relationships. All three networks work with the principal insurance companies offering Medicare Advantage in the area. Those doctors, hospitals, and clinics are in-network. Even the few independent firms in the area also have relationships with the plans.
In other areas, the plans may not be as connected. You need to verify your doctors and hospitals before considering a plan.
What Are The Copays?
A question you need to ask your Medicare insurance agent is: what are the copays? Once you have determined the amount of MOOP you are comfortable assuming, verified your prescriptions and doctors, you look at the copays. Everyone has their own way of evaluating prices. Compare the various copays among plans, doctors, x-rays, MRI’s etc. Narrow down the number of plans. There is no perfect plan. There are always trade-offs.
Extra Benefits in Medicare Advantage Insurance Plans in Omaha, Nebraska
Many people focus on the extra benefits that Medicare Advantage offers, like dental and vision. Those are real benefits and should be weighed. However, dental expenses are usually not life-threatening nor do they run into the tens of thousands like health insurance or prescription drugs. This is a crucial place to ask questions of your Medicare insurance agent.
A particular plan may have a nice dental benefit of $1,500, but if the MOOP on that plan is $7,000 versus another plan with no dental at a $2,800 MOOP, I would favor the plan with the small MOOP. You can always purchase a separate standalone dental plan.
Many people do not realize that Medicare Advantage plans do not have underwriting like Medigap plans. During your Annual Election Period (AEP) October 15th–December 7th, you may change from one plan to the other without answering any health questions. The plan cannot refuse you. You may also change during the course of the year if you have a special reason for changing.
You Can Change During Annual Election Period (AEP) October 15th-December 7th
The Annual Election Period is the time when you may change your Medicare Advantage Plan. You don’t need a reason, but you could have one. You are not happy with the service. Another plan appears with richer benefits or lower MOOP and copays. You plan on doing extensive dental work and you want a plan with more dental for that year. There can be multiple reasons or no reasons for changing. You may change.
Ask Your Medicare Insurance Agent: Does Your Plan Have A National Network?
A concern people have with Medicare Advantage plans is with the network. The network concerns extend quite often beyond the local area. People are concerned about travel, outside of the service area, going to specialists not located in the service area.
Many of the major insurance carriers, including in the Omaha Metro area, have national networks. That is, you can go to doctors and hospitals outside of the local service area and still be in-network and pay in-network prices because the doctors and hospitals participate in the insurance company’s national network. This includes HMO (Health Maintenance Organization) plans. PPO (Preferred Provider Organizations) plans cover doctors and hospitals by design out of the local area. You may pay more, but you will have access. For emergencies, you are covered anywhere on Medicare Advantage plans. For some people, especially those who may travel, this is a concern.
Medicare is incredible health insurance. It comes in various forms to fit your needs and how you wish to be serviced. Medicare Advantage Insurance Plans in Omaha, Nebraska are a powerful way to receive your Medicare. Understanding the trust about Medicare Advantage and sorting through the exaggerations and distortions is important to make sure your needs are authentically served.
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.
Home 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 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 a 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.
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.
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?
A 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.
Once 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.
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.
- A physician must certify that skilled care is needed and must prescribe the plan of care.
- A participating Medicare-approved home health care organization must provide the care.
- The patient must need at least one of the services: intermittent skilled nursing care, physical therapy, speech-language pathology, and continued occupational therapy.
- The patient must be confined to the home.
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.
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.
- 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.
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 distress 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?
When 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.
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
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.
I had a client who had a knee replacement. Usually a knee replacement, even with complications, 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 certifies 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.