Medicare Home Health Care Benefit

As briefly discussed in my article on long-term-care fundamentals, a doctor must order and regularly review a home-health care plan. The doctor must certify that the patient is home-bound (not recommended to leave the house because of a medical condition or cannot leave home without special transportation, wheelchair or walker). The person can only leave home for medical treatment or short/infrequent absences, such as to an adult day care or religious service.

If a primary care physician prescribes a home health care plan, they will specify whether home services are to include: physical therapy (PT), occupational therapy (OT), intermittent skilled nursing (RN), speech pathology, limited home-health aides, and/or occasionally social worker care (counseling). Any combination may be provided but only to the extent that the therapy services will lead to improvement or the condition requires a skilled therapist to establish or perform a maintenance program.

If so, a home health care agency is contacted and they send a nurse out to do a head-to-toe evaluation to decide whether they believe they will qualify for Medicare’s standards. They use OASIS (outcome and assessment information set) standards to assess the patient’s condition.

If the patient qualifies for any one (or all) of these services, Medicare will pay in increments of 60 days (referred to as an “episode of care”). After each episode, the patient’s primary physician and the home health care agency’s director of nursing need to get together to review the patient’s care plan to either re-certify for another episode or to stop services.

  • Medicare looks for fraud when a home-health care agency re-certifies a new episode without the primary doctor’s review.
  • In order for the primary doctor to re-certify a new episode they must confirm that they have seen the patient (face-to-face) within 30 days of the recertification.  
  • The patient's physician is also certifying that you only need part-time or intermittent skilled nursing care (fewer than 7 days a week/less than 8 hours a day over any 21 day period). If you need more than this, the Medicare is no longer eligible for the home health care benefit and they will need to rely on the Medicare long-term-care benefit. The long-term-care benefits offered by Medicare are severely limited.
  • Medicare will typically not approve each of a OT, PT, RN or social worker come to the patient’s home for more than 2-3 days per week, and usually no more than 50 minutes at a time.

 What Medicare Home Health Care Benefit Does NOT Cover

- 24 hour a day care at the home

- Meal delivery/preparation

- Home Health Aide Care (dressing, bathing, toileting), when this is the only care you need.

 

Medicare Long Term Care Benefit

Medicare has limited long-term care benefits (for people who truly need skilled daily care such as injections or physical therapy). Once a Medicare patient has been officially admitted into a hospital (which is different than staying overnight for observation) for three days/two midnights, then upon discharge, Medicare pays for a maximum 100 days of nursing home care (if the patient enters the skilled nursing facility within 30 days of hospital discharge – for the same condition as the hospital stay).

Upon meeting these qualifications, traditional Medicare will pay 100% of the LTC costs for the first 20 days; for the next 80 days, a $167.50 per day (as of 2018, this co-pay changes every year) deductible applies (Medicare supplement + Medicare Advantage + Medigap may cover this deductible)

Medicare only pays for skilled nursing care to treat acute conditions likely to get better or improve (as opposed to custodial care which is for people who need help eating, toileting, transferring, bathing and getting dressed). 

  • Also, if the skilled care would help maintain or slow deterioration, Medicare should cover (for the limited benefit period). 
  • Furthermore, if the patient is received a combination of non-skilled treatment that require a skilled nurse to monitor, Medicare should cover (for the limited benefit period).

While you may think you have some breathing room with the 100 day Medicare long-term-care benefit, practically speaking, when the rehab or nursing home facility realizes that the patient will be there for a significant period of time, they will be watching very closely. Between day 45 and 65, the facility will be looking at whether the patient has a plan to pay for day 101 (when Medicare cuts off). If the patient does not have a plan (or ability) to utilize a long-term-care insurance policy or privately pay, they will be looking for reasons to kick the patient out early. A clear medical necessity must be demonstrated to justify staying the full 100 days. Medicare also penalizes facilities for “over utilization,” which is another incentive for the facility to kick a long-term-care patient out early. There is an appeals process if a nursing facility attempts to discharge a patient too soon, but if you lose the appeal, the costs of the nursing facility must be borne by the appellant patient.

ELDER LAW RESOURCES

Differences Between Medicare and Medicaid

What Does Medicaid Cover?

Medicare Home Health Services