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.
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.
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.
I learned to sing the alphabet before I learned to say it, and from that humble beginning, language opened up to me.
You can’t understand language without first understanding its alphabet. Medicare has a language, and Medicare has an alphabet. It begins with A, B, & D. They are the three essential components of Medicare.
A is for Medicare Part A. A covers the hospital 100% for 60 days but only after you pay a $1,260 deductible out of your pocket. Ouch! Part A is free because you paid for it during your working years. Eligibility for A is 3 months before your 65th birthday, the month of your birthday, & three months after. If you don’t enroll then, there will be a penalty.
B is for Medicare Part B. B covers doctor visits and outpatient procedures, such as, blood work, x-rays, emergency room, ambulatory surgeries, walkers, wheel chairs, oxygen tanks, etc. Part B does cost something. Currently $104.90 per month. Medicare Part B pays 80% of the costs. Your portion is 20%. Important fact about your 20% co-insurance is that there is no cap. As long as the bills roll in, your money rolls out. Bigger Ouch! The penalty for late enrollment for Part B is 10% for every 12 month period.
The final letter is not C. It’s D—D as in drugs. Medicare Part D was started in 2006 after people complained about the crushing cost of medications. Prescription drug plans are administered by private insurance companies approved by Medicare. Prescription Drug Plans (PDP) can range in cost from $20–$50 per month with deductibles and co-pays. There is a penalty for not enrolling in a Part D plan when you are eligible. It accrues each month you are not enrolled and is permanently added to your Medicare premium when you do enroll.
Medical expense can be astronomical. If the correct insurance is not in place with sufficient coverage, costs may surprise and overwhelm you. Not following the eligibility requirements could result in surprise penalties and permanent costs from Medicare. Call 402-614-3389 or email us at info@OmahaInsuranceSolutions.com for a free consultation to make sure all your letters are in place.
Like most children, I learned to sing the alphabet before I learned to read it. From that humble beginning, language opened up to me. Why does that matter when we’re talking about Medicare? You can’t understand language without first understanding the alphabet. Medicare has a language and an alphabet all its own.
Medicare Part A is the first letter in the alphabet and language of Medicare. A isn’t for apple, however. Part A is for hospital insurance, so how much is Medicare Part A deductible for 2021?
First, we let’s discuss what Part A is and what it covers.
What Is Medicare Part A?
Medicare Part A covers four areas of care: inpatient hospital stays, skilled nursing facility stays, home healthcare, and hospice.
Inpatient hospital covers, as you might expect, when patients go to the hospital. Patients can go to the hospital for treatment, they may even stay overnight, but they may not necessarily have been admitted as an inpatient. Inpatient hospital is its own category, billing codes, and Medicare costs. A patient is generally not admitted for an inpatient hospital stay unless the condition is serious enough to warrant at least a two-day hospital stay.
Observation in the hospital is not admittance. You are under hospital observation, but you are not an inpatient. Medicare Part A deductible will not cover observation in 2021, and most Medicare Advantage plans (MA plans) will not cover hospital observation, either. However, some MA plans are starting to.
Check your MA plan’s evidence of coverage before proceeding. Note that a doctor must sign an order for a medically necessary service in the hospital for a person to be admitted as an inpatient.
What Is The Medicare Part A Deductible in 2021?
Part A hospital insurance covers everything during the hospital stay–except doctor’s visits– completely for 60 days, but only after you pay a $1,484 Medicare deductible out of your pocket in 2021, assuming you have no other health insurance coverage.
Medicare Part A does not have a premium. The 1.45% FICA taxes you paid for Medicare during your working years covers your Part A cost. There is only a deductible, no co-insurance.
This applies to each 60 days per event benefit period. Note, that it is possible to have multiple unrelated events overlapping within a 60 day period. In that case, you’d pay multiple deductibles. Ouch!
What Is The Medicare Part A Benefit Period?
The Part A benefit period begins the day of admittance and ends when the treatment stops. A new benefit period does not start until you are without inpatient treatment for 60 consecutive days.
If you are readmitted to the hospital within the 60 days following, the countdown starts again where you left off until you use 60 days.
Medicare Part A Coinsurance Payments Are Covered By?
Once you exceed the first 60 days, you have a co-insurance of $371 per day from day 61-90. Medicare coinsurance is different from Medicare deductible in 2021. Again, this is assuming you have no Medigap policy or other health insurance.
Paying the Part A co-insurance amount is rare because most hospital stays end well before the 61st day.
Medicare Deductibles Affect Insurance Costs
It is important to note for those on Medigap policies or even Medicare Advantage that Medicare deductibles impact insurance costs. This extended coverage is the obligation of your Medigap policy or MA plan. Consequently, the insurance company actuaries must factor in the probability of occurrence and cost.
The cost is transferred to the price of the Medigap plan or co-pays on the MA plan. Many clients wonder why their Medigap plan premium is going up? There are many factors, but when Medicare lowers the amount it will cover, the insurance companies pass on the cost to the consumer.
What Are Lifetime Medicare Reserve Days?
Medicare lifetime reserve days refers to the 60 days a Medicare beneficiary may use once they exhaust the first 60 days of Part A and the additional 30 days with the $371 co-insurance.
The patient dips into the lifetime reserve days Medicare provides. These days, however, are not free. The coinsurance is $742 per day. Once these 60 lifetime reserve days are exhausted, the patient assumes all costs in the hospital, assuming there is no other insurance.
What Does Part A Cover Besides Hospital?
In 2021 once you have paid the Medicare deductible, Medicare Part A covers hospital stays virtually completely: semi-private room, general nursing, drugs prescribed while in the hospital, supplies, and treatments while an inpatient. The various areas within the hospital are also covered life ICU (intensive care units), inpatient rehabilitation, inpatient psychiatric facilities, long-term care hospitals.
Does Part A Cover Skilled Nursing Care?
Most people understand Part A is for the hospital. On the Medicare card itself, the card says “Part A Hospital.” However, many people don’t realize skilled nursing care falls under Part A, as well. The rules of coverage and payment are very similar to the inpatient hospital stays. I discuss skilled nursing in another blog.
Is Home Health Care Covered Under Medicare Part A or Part B?
Home Health Care can fall under Part A. Many people assume it is exclusively under Part B, but there are circumstances when Part A may pay for home health care.
Generally, beneficiaries and doctors approach home health care from the Part B side of Medicare to avoid the high Medicare Part A deductible and the more restrictive rules of hospital confinement.
What is the Medicare Deductible For Hospice 2021?
Part A covers hospice completely with no deductible. Hospice includes hospice nurses, medications, and counseling. Medicare Advantage plans actually do not cover hospice, rather the beneficiary reverts back to Original Medicare, at least for the hospice care. The Medigap policy likewise does not cover the cost. Medicare picks up the entire tab.
That being said, there is some confusion about what hospice covers. I had a client’s family member call to cancel her mother’s supplement. Someone in hospice told her because hospice was paying for everything, she could save money by canceling the Medigap policy. But hospice will not cover things like your primary care physician visiting you, a special hospital bed, or other medical treatments that are not life-sustaining but you might prefer.
Those services fall under Original Medicare and your supplement or your Medicare Advantage plan. For the short time someone is on hospice, I would focus on them rather than a few dollars.
Medicare Part A Deductible Conclusion
I have discussed Medicare Part A as Part A without a supplement or referring to Medicare Advantage. Many Medicare beneficiaries have only Medicare Part A or Part A with Part B. They do not have a supplement, advantage plan, or other insurance. So this speaks to them.
However, to understand Part A and how it fits within the bigger picture of Medicare health insurance, it is important to understand what it is, what it covers, and what it costs in its various iterations.
If this is confusing–and I don’t blame you for feeling that way–give us a call. Medical expenses can be astronomical. If the correct insurance is not in place with sufficient coverage, costs may surprise and overwhelm you. Not following the eligibility requirements could result in surprise penalties and permanent premium hikes from Medicare.
Call 402-614-3389 or email info@OmahaInsuranceSolutions.com for a free consultation to make sure all letters of your Medicare alphabet are in place.