Home healthcare and Medicare:
Comprehensive Overview about Medicare Home Health Care:
This home
health care plan can actually be defined as a skilled health and other medical care
services received at the comforts of your own home as a means of helping you
treat an injury or illness. Home health care includes part-time or intermittent
skilled nursing
Care, as
well as other skilled care services like physical and occupational therapy, and
speech-language pathology (therapy) services. Services may also include medical
social services, and assistance from a home health aide (when needed, if you
are also
Getting
skilled care). In order for Medicare to pay for these services, you must meet
certain eligibility criteria, and the services must be reasonable and necessary
for the agency may do this through its own staff, through an arrangement with
another agency, or by hiring nurses, therapists, home health aides, and medical
social service counselors to meet your needs.
The home
health agency staff will teach you and make you able to recognize the problem
like infection, or shortness of breath
and what to do or who to contact if they happen.
Who is
eligible to get Medicare-covered home
Health
care?
You can
use your home health benefits if you
Meet all
the following conditions:
1. Your
doctor must decide that you need medical care at home, and
Make a
plan for this care.
2. You
must need one or more of the following:
• Intermittent
skilled nursing care
• Physical
therapy
• Speech-language
pathology services
•continued
occupational therapist
3. The
home health agency caring for you must be approved by the
Medicare
Program (Medicare-certified).
4. You
must be home bound or normally unable to leave home
Unassisted.
What Does
Medicare Cover?
In 1965,
President Lyndon Johnson signed the original Medicare program into law. The
program originally covered two portions:
Part Hospital
insurance
Part B -
Medical insurance Part A covers a large portion of hospital-related costs for
eligible
People over the age of 65 and only includes medically necessary
and skilled care, not custodial care. Persons not eligible for coverage can
participate in the program if they pay a monthly fee.
Part B is
optional and pays a portion of non-hospital provided medical care, such as
doctor visits and other outpatient services. There is a monthly fee for this
program.
Part C -
"Medicare" + Choice, now known as "Medicare Advantage"
It
operates like the healthcare coverage provided by most employers.
Part D -
Prescription drug coverage
Part D is
an optional insurance program that charges a monthly fee in exchange for
prescription drug coverage. The monthly cost varies widely depending on the
coverage options you choose.
Types of
home health care that Medicare will pay for:
Medicare
covers the following types of care:
a)
Skilled nursing services and home health services
b)
Skilled therapy services
c) Medical
social services
d)
Medical supplies
e) Durable
medical equipment.
Medicare and Long-Term Care
The
Medicare program is designed to provide for medical care, not the cost of
long-term care (LTC). As such, Medicare's coverage for long-term needs is
extremely limited. Assuming you qualify, Medicare may pay up to 100% of your
costs in a nursing home for the first 20 days in a benefit period. Once 20 days
have passed, you must pay a hefty co-insurance amount for days 21 through 100
for each benefit period.
In order
for Medicare to pay for your LTC costs at all, you must meet three criteria:
The
72-Hour Rule - You must have been hospitalized for at least three full days and
three full nights. Many hospital stays are three days and two nights. For
example, you might go in for a hip replacement on Monday morning and leave
Wednesday afternoon.
Medical
Necessity - Your care must fulfill the following requirements:
It must
be medically necessary.
It must
be care that can only be given in a nursing home, in most cases by skilled
personnel.
It must
result from the condition for which you were hospitalized.
Places
Where Care Can Be Given - In almost all cases, patients leaving a hospital go
straight to a nursing home for further care.
Medicare
Home Health Care Rules
1)
Medicare May Pay for Home Health Care if:
1. Home
health care is needed to appropriately treat the medical condition, and is
considered medically necessary.
2. The
patient is “homebound.”
3. A "face to face encounter" (medical
visit) is required for traditional Medicare patients within the 90 days prior
to, or the 30 days following, the start of home care services. .
4. There
is a Plan of Care approved and signed by the patient’s physician.
5.
Skilled services—such as nursing, physical therapy or speech therapy—are
required and cannot be performed by a nonmedical person.
6.
Required care is intermittent or part-time (usually less than 35 hours a week).
7. The
patient is expected to improve—goals are set and progress is seen.
8. The
patient’s home care agency is approved by Medicare.
9. Home
care services are delivered in the patient’s primary place of residence.
2)
Medicare Will Not Pay for Home Care if:
1) The
patient’s condition is “chronic and stable.”
2) The
patient is not likely to improve with home care.
3) The
patient is not homebound.
4) A
"face to face encounter" (medical visit) documentation for
traditional Medicare patients is not submitted and signed by a physician within
the 90 days prior to, or the 30 days following, the start of home care
services.
5) Home
care is not medically necessary to treat the patient’s medical condition.
Only
assistance with ADLs is needed.
What is
Home Health Compare?
Home
Health Compare can help you or your family or friends choose a quality home
health agency that has the skilled home health services you need. The
information on Home Health Compare:
Helps you
learn how well home health agencies care for their patients
Shows you
how often each agency used best practices when caring for its patients and
whether patients improved in certain important areas of care
Shows you
what other patients said about their recent home health care experience.
The
information in Home Health Compare should be looked at carefully.
NOTE:
Medicare will not cover home health services provided by a home health agency
that has not been Medicare-certified.
Our
Company Values: the unchanging beliefs we hold and practice
Integrity:
Honest,
ethical, professional, accountable, treats others with dignity, respectful,
loyal
Customer
Service:
Exceeds
customer expectations, friendly, flexible, adaptable, committed, compassionate,
dependable
Innovation:
Forward
thinking, seeks knowledge, self-motivated, positive 'nothing is impossible'
attitude, thinks out of the box
Teamwork:
Follow
through, commitment to the team, communication with the team, respect, dedication
to positive outcomes
Our
Purpose: our reason for being in business
To make a
positive impact in the health and lives of the people we serve.
What Are the Pros & Cons of Home Health
Care?
a) Home bound Requirement
The most
common con to home health care benefits is the requirement that the patient be
home-bound. In order for Medicare and most other insurance providers to pay for
home health care, the patient must be unable to leave the home to visit a
treatment facility or for any other purpose. If leaving the home requires
significant assistance, such as the use of hands-on assistance by another
person, is extremely taxing for the patient, or is infrequent and for medical
treatment only, the patient may also be considered home-bound.
b)Short-Term
Treatment
Home
health care is generally considered to be a short term treatment, typically
lasting approximately six weeks. There is no regulation specifying the length
of time a patient can receive home care, however, the home health agency must
continue to prove that the patient has a need for skilled care.
c) Costs
Durable medical
equipment, such as wheelchairs and oxygen concentrators, and medications are
only partially paid for by the home health agency, with a usual co-payment of
20 percent for the patient. However, this cost can be significantly less than
if a patient were paying the total cost out of pocket.
D) The
Home Component
It's
possible for patients to return home from the hospital sooner and receive home
health care in lieu of extended hospital stays, in some circumstances.
e)
Private Pay Options
These
services must be paid for privately. Non-medical home care agencies provide a
range of services, including housekeeping, personal care, transportation, meal
preparation, and more, although the services can be quite expensive.
f) Fraud
The home
health industry is subject to frequent scrutiny, being suspect of falsifying
documentation in order to qualify individuals for care or bill for services not
provided. This practice drives up the cost of home health care, and contributes
to skyrocketing health care costs in general.
Conclusion
The rules
and regulations covering Medicare can be difficult to understand, especially
when it comes to needing assistance with Ad Ls or needing medical care. Not
understanding the difference could cost you or your family dearly. Medicare may
cost more and provide less in coverage and benefits than you may have thought.
Investing time and energy into determining the best combination of coverage
options can help you avoid unpleasant and expensive surprises down the road.
