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Home Health
Care is one of the services that is 100%
paid for by Medicare (Part A, or Part B if you don't have Part A). I
will address this subject in some detail to try to clear up some
misconceptions.
You must meet
the following conditions before you can receive the services:
The doctor prepares a plan that describes the services and
care you must get for your health problem. There must be a need for at least one
of the following: part-time or intermittent skilled nursing care, or
physical therapy, or occupational therapy or speech therapy, as determined
by your doctor. You must be
homebound. This means that the
doctor has decided that leaving home requires “considerable and
taxing effort and assistance.”
You may leave home for medical treatment, religious services or
personal service, such as a barber.
Medicare will
pay for skilled nursing and home health aide services combined to total
less than 8 hours per day and a maximum of 28 hours per week. Hour and day limits can be increased
by your doctor in special situations.
The health aide services include assistance with personal care
such as bathing, using the toilet and dressing. This type of service
can be a major relief to the family caregiver. Such assistance is
called "custodial" or unskilled care, but it is covered
because it is related to and supportive of skilled care treatment of
the illness or injury. It is important to understand that Medicare does
not pay for "solely" custodial care. Medicare will cover home
health aide services because you are also getting skilled nursing or
therapies. In addition to the
above benefits, Medicare pays 100% for medical supplies like wound
dressings and medical social services.
The Home Health Care plan must be reviewed by your doctor and
home health agency at least once every 60 days.
In the case of
traditional (non-HMO) home health services there is a 20% coinsurance
share of the Medicare approved charge due from the beneficiary for
Medicare covered medical equipment such as wheelchairs. There will be
extra costs if the supplier doesn't accept assignment. The agency (or
nurse or therapist visiting you) must inform you if items they will
provide (or order for you) are not covered by Medicare. If they don't
tell you -- ask. You want to avoid misunderstandings resulting in
surprise out-of-pocket expenditures. Items like shower grab bars,
toilet seats or similar items may be excellent safety suggestions, but
they may not be considered medically necessary.
Medicare home
health care is generally thought of as short-term care to provide
treatment for an illness or injury (acute illness) to help you get
better and regain your independence.
Most people don’t realize that there is another
“side” to Medicare home health care. It is stated as follows in the
Centers for Medicare & Medicaid booklet “Medicare and Home
Health Care.” : “The
goal of long-term home health care (for chronically ill or disabled
people) is to maintain your highest level of ability or health, and
help you learn to live with your illness or disability.”
Not
withstanding the above broad principle of CMS, patients may be denied
further service by their home care agency. The home care agency decides that the
patient’s condition is now “stable” and doesn’t
need any further services. The
counter argument by the patient’s advocate is that “maintenance
needs to continue to slow or prevent the deterioration of a medical
condition or body parts.”
And at this point in time, it would be helpful to have the
support of the doctor’s submitted detailed plan for health care,
maintenance and/or rehabilitative services the patient needs. Therefore, in cases of chronic and
long term conditions, the doctor should pay particular attention to his
“detailed” plan.
The advocacy/appeals process can be outlined as follows:
You have the right to the same benefits in a Medicare HMO
that you have in traditional Medicare.
If you are told by your Home Care Agency or Managed Care plan
that services are to be terminated, request a written notice stating
the reasons for the termination and the procedure necessary to appeal
the decision. Assistance of your
doctor in this appeal will be of major importance. I can refer you to two organizations
with long time experience in Home Health Care that can be helpful to
you in problem situations -- Medicare Rights Center, NYC Tele. No.
1-212-869-3850. O/S NYC 1-800-333-4114 and Center for Medicare
Advocacy, Willimantic Conn. Tele. No. 1-800-262-4414 in Conn. or
1-860-456-7790 (outside Conn.).
Lab Tests is another service paid for 100% by Medicare, but I find too
many cases where one or more of the tests are rejected to the surprise
of the beneficiary. The three main reasons for rejection are the
following: tests are being used to screen for early or hidden signs of
disease; secondly, and though screening is allowed in some cases (for
example, pap smears every two years), you have had the test too frequently; and thirdly, the
test is considered medically unnecessary, given the diagnosis of the
doctor. However, if you recognize the rejected test as one that has been
paid in the past, I would give this information to the doctor's
office. They can then make
certain that the diagnosis codes were correctly recorded on the order
slip to the lab. The fact that you signed an Advance Beneficiary Notice
(ABN), agreeing to pay if Medicare denies coverage, should not deter
you from making the request. You have a valid reason in spite of the
fact that, in lab testing, past approval may not be a precursor of the
future. Your doctor has ordered the tests based on a wide range of
factors, including generally accepted medical practice. However, Medicare may or may not
consider these factors when setting their rules. This causes
uncertainty as to whether a test will be approved or disapproved. The
reality is that we are going to our chosen doctors because they have
our confidence to manage our health, and it is generally recognized
that lab tests are very important to good health care. That, it seems
to me, is the bottom line. And talking about good health care, there is
good news in the area of preventive medicine, since Medicare has been
adding more preventive services in the last few years, and I will be
addressing this subject in the following portion.
Medicare is providing coverage for the following Preventive Services, to
help you stay healthy. As I have stated in the above Lab Test portion,
Medicare has been adding preventive services in the last few years. And
as I indicate below in the description of current and soon to be
effective services, that trend is continuing -- more and more.
Therefore, you should check every six months with the various Medicare
beneficiary information sources for the current preventive services
benefits. Please note that at risk patients for a particular condition
will have easier access to the services, so you should discuss with
your doctor if you fit this category. This is highly important coverage
which you should use as much as possible.
One-Time Initial “Welcome to
Medicare” Physical Exam Medicare covers an initial physical
exam performed within six months of a beneficiary initially enrolling
in Part B. The exam will include
a thorough review of your health, education, and counseling about the
prevention services you may need, as well as referrals for other
care. Coverage for the physical
does not include any lab tests.
The exam will also cover measurement of height, weight, and
blood pressure, and an electrocardiogram. As of January 1 2007 Medicare will
cover ultrasound screening for abdominal aortic aneurysms for at risk
individuals.
Colorectal Screening
Medicare will cover the following colorectal screening tests: (1) A
screening fecal-occult blood test once every 12 months for individuals
over 50. There is no co-insurance charge or Part B deductible; (2) a screening
flexible sigmoidoscopy every four years for individuals over the age of
50; (3) a screening colonoscopy every two years for the following high
risk individuals: you have a history of inflammatory bowl disease,
colorectal cancer or polyps; you have a family history of colorectal
cancer or polyps; (4) doctor can substitute a Barium enema for
sigmoidoscopy or colonoscopy; (5) Effective
July 1, 2001: a colonoscopy screening once
every ten years but not within 4 years of a screening flexible
sigmoidoscopoy. Other tests, procedures and modifications will be
covered as Medicare finds appropriate.
As of January 1, 2007 colorectal cancer screening is exempt from
the Part B deductible
Diabetes Services
(1) Medicare will provide coverage for home blood glucose monitors,
testing strips and lancets for all diabetics (insulin users and
non-users). (2) Medicare will cover outpatient diabetes self-management
training services if the physician certifies that the services are
needed to provide the individual with the necessary skills and
knowledge to manage his/her own condition, because he/she is at risk
for complications from diabetes.
(3)There is a new Diabetes Screening (Fasting Plasma
Glucose Test) beginning January 1, 2005 up to twice per year for
individual at high risk for diabetes.
High risk individual include those with high blood pressure,
dyslipidemia (history of abnormal cholesterol and triglyceride levels),
obesity or a history of high blood sugar. Medicare also covers these tests if
you answer yes to two or more of these questions: 65 or
older?-overweight?-family history of diabetes?-have a history of
diabetes during pregnancy or delivery of baby weighing more than 9
pounds? (4) Medical Nutrition
Therapy is also covered for people with diabetes or renal disease when
referred by a doctor. These
services can be given by a registered dietician or Medicare-approved
nutrition professional and include a nutritional assessment and
counseling to help you manage your diabetes or kidney disease.
Bone
Mass Measurement (Bone Density Test)
Bone mass measurement procedures are especially needed for the
following high-risk persons: an estrogen-deficient woman at clinical
risk for osteoporosis; an individual with vertebral abnormalities; an
individual receiving long-term glucocorticoid steroid therapy; and
individual with primary hyperparathyroidism; or an individual being
monitored to assess the response to, or efficacy of, an approved
osteoporosis drug therapy. As of
January 1 2007 at risk beneficiaries will now include persons
undergoing long term steroid therapy.
Mammogram Screening
Medicare will provide coverage once every 12 months for female
beneficiaries ages 40 and over. You can also get one baseline mammogram
between ages 35 and 39.
Pap Smear and Pelvic Examination
Medicare provides coverage for a pap
test and pelvic and breast examinations every two years. Women who are at high risk for
cervical cancer can have these tests covered once a year.
Prostate Cancer Screening
Medicare will cover once every 12 months a cancer screening test for
men age 50 and over. The test consists of the following procedures: (1)
a digital rectal exam every 12 months (2) a prostate-specific antigen
blood every 12 months (3) after 2002 coverage of other procedures as Medicare
finds appropriate for the purpose of early detection of prostate
cancer.
Glaucoma Screening
Glaucoma screening once a year for persons at risk of glaucoma
including people with diabetes, a family history of glaucoma, or
African-Americans who are age 50 and over.
Shots (vaccinations)
Flu shot-once a year in the fall or winter.
Pneumonia shot-one may be all you ever need. Ask your doctor.
Hepatitis B shot-If you are at medium to high risk for hepatitis.
Cardiovascular Screening Medicare covers cardiovascular
screening blood tests for total cholesterol, high density lipids and
triglyceride levels. Tests will
be limited to once every five years.
Updated: January 14, 2008
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