Jane’s mother, Anne, suffered a stroke and a broken pelvis, and will be leaving the rehabilitation center she was staying in this week. When she returns home, she desperately needs a health aide to assist with bathing, transferring from bed to chair with a lift, and changing a bandage from a deep wound, among other things.
Anne has a Medicare plan that states that she can get 35 hours a week of home health care, and that she can use some of these hours for nursing care, physical therapy, and occupational therapy. However, even though she really needs the services described above (help with transferring etc.), Medicare won’t cover them!
How can this be? According to Phillip Moeller, PBS Medicare Expert, “(o)ne of the greatest gaps in Medicare coverage is that it does not help to pay for home-based care, unless such care is requested by a physician as medically necessary.” And even then, actually getting the care is extremely unlikely.
How does someone qualify for Medicare covered home health benefit?
• If you are homebound, meaning you need the help of another person or special equipment (walker, wheelchair, crutches, etc.) to leave your home or your doctor believes that leaving your home would be harmful to your health.
• If you need skilled nursing care on an intermittent basis (as little as once every 60 days to as much as once a day for three week) or you need skilled therapy services, which can be physical, speech, or occupational therapy.
• If your doctor signs a home health certification stating that you qualify for Medicare home care because you are homebound and need intermittent skilled care. The certification must also say that a plan of care has been made for you, and that a doctor regularly reviews it.
• If you receive your care from a Medicare-certified home health agency (HHA).
If you qualify, what does Medicare cover?
According to the Center for Medicare Advocacy, if you qualify for the home health benefit, Medicare covers the following types of care:
• up to 35 hours a week of home-based care — provided by nursing and home health aides — to people who are housebound and for whom such care is prescribed as medically necessary by their doctor. The home health benefit also includes physical, occupational or speech-language therapy.
• skilled nursing care on an “intermittent” and “part-time” basis and also for home-based medical social services and for home health aides, who are allowed to perform certain personal services that stem from the patient’s underlying medical needs, but which are not the same as custodial care, which is not covered by Medicare.
Even if you qualify, Medicare home health benefits are limited and sometimes unavailable
Even if you qualify, you may not get the services you need, because Medicare’s home health care benefit is very limited.
According to the Center for Medicare Advocacy associate director Kathleen Holt, allowable benefits are broader than most people realize, but “it doesn’t matter what’s actually covered, because home health agencies routinely decline to provide even the skimpier services that Medicare publicizes to Medicare enrollees who request them.”
These are some issues seniors have encountered when it comes to Medicare and home care:
• What they cover: Medicare will only pay insurance claims to home health agencies who are registered and approved by Medicare.
• Qualified agencies aren’t required to provide benefits to Medicare patients: Medicare has developed an extensive quality rating system, so consumers can find the most qualified agency. However, there is absolutely no requirement that an agency actually provide home health services when Medicare enrollees request them.
• Agencies turn away business because of Medicare’s increasing emphasis on paying for health care that actually helps patients get better. This means that home health agencies are rewarded for treating patients who are likely to get better.
• Shift to fee-for-results care: Medicare and Congress have supported the shift from fee-for-service health care to fee-for-results care. So, agencies are effectively discouraged from treating people with long-term chronic conditions who may be technically qualified for services, but don’t get services because they are unlikely to get better.
• More fraud surveillance: Medicare has been stepping up its surveillance of fraud in home health care services, and this has added to the reluctance of home health agencies to accept Medicare patients, because they are afraid of being investigated for fraud. While Medicare stresses that the benefit should be considered a short-term solution, technically it can be renewed for consecutive 60-day episodes of care. So, as long as a doctor prescribes continuation of such care, Medicare is supposed to cover it. However, care lasting beyond 60 days has become a red flag that triggers a fraud investigation by the outside fraud contractors hired by Medicare. Home health agencies are not eager to have their Medicare licenses threatened by these types of situations.
The nonprofit Center for Medicare Advocacy has recently experienced a growing volume of complaints from Medicare enrollees who have been denied home-based care even though they are qualified to receive it and it should be covered by Medicare.
Medicare does not pay for nursing home long-term care
Not only does Medicare in-home coverage not work the way it should, please know that Medicare does not pay one penny for long-term care. Medicare ONLY pays for short-term therapy and skilled care in a nursing home for up to 100 days. For long-term care, the main government benefit is Medicaid, but there are strict and very complex financial requirements that must be met in order to qualify for Medicaid, including the requirement of having less than $2,000 of countable assets to your name. However, with proper Medicaid asset protection planning, almost everyone can eventually qualify for Medicaid when needed. If you or a loved one who is nearing the need for long-term care or already receiving long-term care or if you have not done Medicaid Planning, Estate Planning or Incapacity Planning (or had your Planning documents reviewed in the past several years), please call us to make an appointment for an initial consultation:
Fairfax Medicaid Planning: 703-691-1888
Fredericksburg Medicaid Planning: 540-479-1435
Rockville Medicaid Planning: 301-519-8041
DC Medicaid Planning: 202-587-2797
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About Evan H Farr, CELA, CAP
