What are Medicare's Home Health Services?
Medicare beneficiaries can receive health care services in the home. Home health services can include:
Who is Eligible to Receive Home Health Services?
In order to receive Medicare Home Health Services :
You must be a Medicare beneficiary.
Even if you are enrolled in a Medicare managed care plan, such as a health maintenance organization (HMO), you are eligible for the same home health services as all other Medicare recipients.
You must be restricted in your ability to leave home.
This means that you require the help or supervision of another person, or you use a supportive device such as a cane or walker. You can leave the home as often as you need for medical treatment. Non-medical absences must be either infrequent, for a short period of time, or against medical judgment. If leaving home requires a considerable or taxing effort for you, you can request home health services.
You must need either skilled nursing care on an intermittent basis or physical therapy or speech therapy.
Skilled nursing includes non only "hands-on" treatment, but observation of your changing condition. There is no requirement that your condition must improve.
Intermittent can mean skilled nursing case as infrequently as once every 62 days. Some people can need a nurse less than once every 62 days and still receive home health aide services, as long As they have a regular and predictable need for a nurse. For instance, you may need a nurse to assist you in administering B12 injections once every 90 days.
You must have a doctor prescribe the home-based care.
This means that if you are enrolled in a managed care plan, the care must be authorized by either your primary care physician or the plan.
How Do I Get Home Health Services?
If your think you may be eligible for home health benefits, ask your physician to develop a plan of care for you. If you are hospitalized, you may aks the hospital discharge planner to set up these services for you. You can also ask a nurse from a home health provider to evaluate your need for home care services and to develop a plan of care. In a managed care plan, you must get prior approval for an evaluation.
The nurse will visit your home, develop a plan of care, and submit her plan to your physician for final approval. You must get home health care services from a provider that is Medicare-certified or selected by your managed care plan.*
Even if you have a chronic, terminal, and/or degenerative condition, home health coverage may be available to you. For example, you may need skilled nursing or therapy services to prevent or slow further deterioration or to preserve current capabilities.
*For a list of you local Medicare-certified home health providers, see "nursing" in the yellow pages, or call your local Council on Aging of the Massachusetts Home Care Association ElderLine: 1-800 AGE-INFO (1-800-243-4636)
How Much Will I have to Pay for Home Health Services?
Unlike other Medicare services, Medicare home health benefits require no co-payment or deductible amounts. There is an exception for durable medical equipment where you musty pay a 20% co-payment.
Is There Any Difference If I am Enrolled in a Managed Care Plan?
If you are enrolled in a managed care plan, you must get prior approval from your primary care physician and/or the managed care plan in order to get home health benefits. If you request home health benefits and approval is denied, either all or in part, you should be notified in writing. However, if you do not get notified in writing, you can still appeal.
How Long Am I Entitled to Home Health Services?
You can receive home health services for as long as you continue to meet the coverage criteria. You can receive a combination of home health services for up to seven days per week and up to 28 hours per week as long as the need for these services is documented by the home health provider. In addition, you can receive up to 35 hours per week of daily services as long as the need for these services is for a finite period of time. A terminal condition, for example, might allow you to qualify for these increased hours.
What Types of Home Health Services Are Available?
Some examples of home health services covered by Medicare are:
You have hypertension and suffer from dizziness and weakness. Your doctor is concerned that your blood pressure is too low and has stopped your hypertension medication. Home health coverage will allow a nurse to observe and monitor your blood pressure until it remains stable and in a safe range.
You were recently diagnosed as a diabetic. You need a skilled nurse to teach you to self inject, to manage your insulin, to understand the signs and symptoms of insulin shock, and how to respond to emergencies. The teaching services would be covered as a home health benefit.
You recently broke a leg bone which has not healed and is unstable. You need regular exercise to maintain function until the bone heals. A physical therapist visits to make sure that your leg is properly aligned during your maintenance exercises. Medicare will cover the therapist's services.
You have Alzheimer's disease and get confused about whether you took your medications and how much you are supposed to take. Medicare will cover a nurse to come to your home to assess your medical symptoms for medication compliance , and to ensure that your overall care plan is adequate.
You have multiple sclerosis and require regular exercise so that your condition does not deteriorate. Medicare will cover a physical therapist to come to your home and ensure that your exercise program remains appropriate.
Although you are homebound, your managed care plan requires you to obtain your physical therapy at their outpatient facility. You also require a nurse to come to your home to change your catheter once a month and the daily assistance of a home health aide with bathing and dressing. Because you leave home for a medical service, the managed care plan will cover the nursing and home health aide visits in your home.
These are just a few examples of the types of services you can get if you are determined eligible for Medicare's home health benefit. Remember, Medicare will also cover home health aides or social workers if Medicare is covering a nurse or therapist.
What if I Disagree with My Health Care Provider?
Sometimes you physician, the Medicare-certified home health provider, your managed care plan or Medicare may disagree with you about home health benefits. You always have the right to appeal. If you disagree, contact the Massachusetts Medicare Advocacy Project. They can help you advocate for health care you may be entitled to.
Assistance with Medicare issues for elderly and disabled Massachusetts residents
If you have been told your Medicare Home Health is being cut back or terminated...
If you are on Medicare, and your Home Health or Visiting Nurse agency recently told you that you hours of care are being cut back...
Here's what you should do:
ASK your agency: "Why is my care being cut back?" Write down the answer you are given.
ASK your agency to give you a WRITTEN NOTICE that explains why you are being cut back.
ASK your doctor if he or she would call your home health agency and urge them NOT to cut back your home health care.
If for any reason you believe you have been inappropriately cut back, call the Medicare Advocacy Project at 1-800-323-3205 to learn more about your rights.
You have the right to challenge a decision to cut back or end your Medicare home health benefits.
THE NEW REIMBURSEMENT SYSTEM AFFECTS MEDICARE HOME HEALTH CARE COVERAGE
What beneficiaries, providers and the public need to know:
The federal Balanced Budge Act of 1997 made some drastic changes to the Medicare program, generally, and to the home health benefit, specifically. You should know that:
The new home health reimbursement system will "cap" the amount that home health agencies can be paid for each patient, regardless of medical need.
The annual per patient "cap" is different for every agency.
A patient with a chronic medical condition, such as multiple sclerosis or Alzheimer's disease, may need five or more visits weekly or more than 200 visits per year; the average Massachusetts agency "cap" will, however, only pay for about 75 visits annually.
The medical criteria to qualify for home health services have not changed. Medicare allows people who are homebound, under the care of a physician and in need of intermittent skilled nursing or physical or speech therapy to receive home health services for as long as they are medically necessary.
Although the number of visits should be based on each patient's medical needs., the new reimbursement system threatens medically necessary care by not providing adequate reimbursement to home health agencies. Thus, even the most caring and well-managed agency will not be able to provide care regularly to patients in excess of the per patient "cap."
If home health care enables you to remain in your home, you should:
Talk about your needs and care plan with your home health nurse;
Be clear about the services you need: and
Write or call your Congressmen. Let Congress know that they cannot refuse to pay for services which patients need and to which, within the Medicare program, patients are entitled. Tell them to repeal the home health care "Interim Payment System."
More tips on what to do in individual cases:
Report inappropriate denials or terminations to Health Care Financing Administration (HCFA), (617) 565-1232. Darrell Spencer or Margaret Leoni-Lugo.
Share with agency or HCFA the assessment of an outside nurse or physician, such as the home care nurse who evaluates the beneficiary.
Talk with physicians and share coverage criteria.
Advise physicians that if they prescribe specific care, it should be covered.
If there is no skilled need, convince agency to continue services until alternative services are/can be arranged.
Advise beneficiary of right to written notice and the right to have a "no-payment" bill submitted and care continued. However, remember that beneficiary can be required to pay for care received pending a Medicare determination, which can take several months.
Try to get support from physician or agency.
Remind agency head, if necessary, that inappropriately terminating or denying service violates their Conditions of Participation in Medicare.
Be clear about what coverage law provides in advocating with agency, health care financial administration and/or physician.
Call the Medicare Advocacy Project for advice or assistance.
Collect Client stories.
Involve the media.
For some beneficiaries, there may not be anything that can be done. Medicare only covers home health services when there is a "skilled" nursing or therapy need. If there is clearly a skilled need, it should be possible to convince the agency to restore services or to find another agency that will agree to provide care. However, if it is not clear that there is a skilled need, it will be difficult to restore Medicare services. It is only possible to appeal to Medicare successfully when skilled services have been received and billed to Medicare. There is no prior approval process for home health services. Thus, if the agency believes Medicare will deny coverage and stops providing services before Medicare issued a denial, there is no way to appeal unless you pay the agency out-of-pocket to continue providing services.
However, it is inappropriate to intimidate beneficiaries, such as by threatening client with termination of services if reduction appealed, or physicians, such as by intimating that their prescribing what they believe to be medically necessary home health services could be fraud.