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
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
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.
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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.
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.
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.
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.
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.