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Helping clients understand Medicare’s home health benefitSlide2
The Medicare Rights Center is a national, nonprofit
consumer service organization that works to
ensure access to affordable health care for older adults and people with disabilities through
Counseling and advocacy
Educational programs
Public policy initiatives
Medicare Rights Center
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This toolkit for State Health Insurance Assistance
Programs (SHIPs), Area Agencies on Aging (AAAs),
and Aging and Disability Resource Centers (ADRCs)was made possible by grant funding from theNational Council on Aging.
The National Council on Aging is a respected national leader and trusted partner to help people aged 60+ meet the challenges of aging. They partner with nonprofit organizations, government, and business top provide innovative community programs and services, online help, and advocacy.
National Council on Aging
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Learning objectives
Understand Medicare basics
Outline home health basics and Original Medicare’s eligibility requirements for coverageReview services covered under home health benefitKnow how to counsel clients about their rights when receiving home health care Page 4Slide5
Medicare basics
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What is Medicare?
Federal program that provides health insurance for
Those 65+Those under 65 receiving Social Security Disability Insurance (SSDI) for a certain amount of timeThose under 65 with kidney failure requiring dialysis or transplantNo income requirementsTwo ways to receive Medicare benefits Page 6Traditional program offered directly through federal governmentPrivate plans that contract with federal government to provide Medicare benefitsOriginal Medicare
Medicare AdvantageSlide7
Medicare eligibility – 65+
After turning 65, individual qualifies for Medicare if they
Collect or qualify to collect Social Security or Railroad Retirement benefitsOR are a current U.S. resident and eitherA U.S. citizenOR a permanent resident having lived in the U.S. for five years in a row before applying for Medicare Page 7Slide8
Medicare eligibility – under 65
Individual under 65 qualifies for Medicare if
They have received Social Security Disability Insurance (SSDI) or Railroad Disability Annuity checks for total disability for at least 24 months Exception: If individual has amyotrophic lateral sclerosis (ALS) there is no waiting period, and they are eligible for Medicare when they start receiving SSDIOR, they have End-Stage Renal Disease (ESRD or kidney failure), and they or a family member have enough Medicare work history Page 8Slide9
Parts of Medicare
Medicare benefits administered in three parts
Part A – Hospital/inpatient benefitsPart B – Doctor/outpatient benefitsPart D – Prescription drug benefit Original Medicare includes Part A and Part BPart D benefit offered through stand-alone prescription drug planWhat happened to Part C? Medicare Advantage Plans (MA Plans)Way to get Parts A, B, and D through one private planAdministered by private insurance companies that contract with federal governmentNot a separate benefit: everyone with Medicare Advantage still has Medicare Page 9Slide10
Part A-covered services
Inpatient hospital care
Care provided to individual formally admitted into the hospital by attending physicianInpatient skilled nursing facility careShort-term, post-hospital extended care at lower level of care than inpatient hospital careHome health careCare to treat illness or injury in the homeOften provided by licensed nurse or therapist, including therapy, skilled nursing, and personal care (if skilled care also required)Hospice careComprehensive care for people who are terminally ill Page 10Slide11
Part B-covered services
Physicians’ services
Medically necessary services provided to individual by doctor on outpatient basisEmergency room visitsPreventive care Care intended to detect and prevent illness or keep beneficiary healthy, such as cancer screeningsHome health care Durable medical equipment (DME)Equipment that serves medical purpose, is able to withstand repeated use, and is appropriate for use in homeEmergency ambulance transportation (in very limited cases) Page 11Slide12
Medicare excluded services
Most dental care
Most vision careRoutine hearing careMost foot careMost long-term careAlternative medicineMost care received outside the U.S.Personal care if there is no need for skilled careMost non-emergency transportation Note: Medicare Advantage Plans (or Medicaid if beneficiary qualifies) may cover these services Page 12Slide13
Home health basics
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Overview
Wide range of health and social services delivered in home to treat illness or injury
Covered services include skilled nursing, therapy, and home health aide careOriginal Medicare pays in full for most services*At minimum, Medicare Advantage Plans must provide same level of home health care as Original MedicareMay impose different rules, restrictions, and costs Page 14Slide15
Coverage requirements
Original Medicare covers home health services if:
Beneficiary is homeboundBeneficiary needs skilled nursing services and/or skilled therapy on an intermittent basisBeneficiary has face-to-face meeting with doctorBeneficiary’s doctor signs home health certification confirming that beneficiary is homebound and needs skilled careAnd, beneficiary receives care from a Medicare-certified home health agency Page 15Slide16
Homebound requirement
Medicare considers an individual homebound if:
They need assistance from another person or medical equipment to leave home, or doctor believes their condition could worsen if they leave homeAnd, it is difficult for them to leave home and they typically cannot do soDoctor must evaluate individual’s condition and certify that they are homeboundBeneficiary may leave home for medical treatment, religious services, and/or to attend licensed or accredited adult day care center without putting homebound status at risk. Short, infrequent absences for non-medical events (family reunion, funeral, graduation) also should not affect homebound status. Page 16Slide17
Intermittent means:At least once every 60 days
At most once per day for up to three weeks
Period can be longer if need for care is predictable and finiteIndividual must require skilled nursing of skilled therapy on intermittent basis to qualify for home healthIntermittent care Page 17Slide18
Face-to-face meeting
Beneficiary required to have face-to-face meeting with doctor either:
Following qualify as face-to-face meeting:Office visitHospital visit In certain circumstances, meeting facilitated by technology (such as video conferencing) Page 18Within 90 days before starting home careOr, 30 days after first day individual receives careSlide19
Home health certification
Beneficiary’s doctor must sign home health certification confirming that:
Beneficiary is homeboundBeneficiary needs intermittent skilled nursing or therapy servicesDoctor has approved plan of care for beneficiaryFace-to-face meeting requirement was metDoctor should review and certify home health plan every 60 daysFace-to-face meeting not required for recertification Page 19Slide20
Plan of care
Home health agency (HHA) should assess beneficiary’s condition to create plan of care
Includes:Types of health services an items individual needsFrequency individual will receive servicesPredicted outcomes of treatmentDoctor must sign plan of careInitial plan of care and home health certification lasts 60 daysBoth can be renewed for as many 60-day periods as necessary, as long as doctor continues to signBeneficiary should speak to their provider to suggest modifications to plan of care Page 20Slide21
Part A and B coverage of home health
Beneficiaries with only Part A will have all their services covered under Part A
Beneficiaries with only Part B will have all their services covered under Part BPart A covers up to 100 visits by a home health agency during a home health spell of illness, so long as the following conditions are met:Hospital inpatient for three days in a row*Receive home health care within 14 days of being discharged from a hospital or SNFIf beneficiary does not meet Part A coverage requirements, their home health services will be covered under Part B Page 21Slide22
Medicare Advantage Plans must follow Original Medicare’s rules for providing care, but can impose different network rules, restrictions, and costsPlan may require:
Beneficiary uses in-network HHA
Prior authorization or referral before covering careCopayment for careMedicare Advantage home health coverage Page 22Slide23
Home health care-covered services
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Skilled nursing care
Services performed by or under supervision of licensed or certified nurse
Includes:InjectionsTube feedingsCatheter changesWound careObservation and assessment of beneficiary’s conditionManagement and evaluation of beneficiary’s plan of care Page 24Slide25
Amount of coverage
Original Medicare covers skilled nursing services up to seven days per week for no more than eight hours per day and 28 hours per week
In some circumstances, Original Medicare covers up to 35 hours per week Page 25Slide26
Skilled therapy services
Services reasonable and necessary to treat illness or injury, performed by or under supervision of licensed therapist
Includes:Physical therapy (PT)Speech-language pathology (SPL)Occupational therapy (OT) Page 26Slide27
Home health aide
Aide that provides personal care
Up to seven days per week for no more than eight hours per day and 28 hours per weekIn some circumstances, up to 35 hours per weekIncludes activities such as:BathingToiletingDressingMedicare does not pay for aide if individual does not need skilled care Page 27Slide28
Other home health services
Medical social services
Medicare covers services ordered by doctor to help individual with social and emotional concerns related to illnessMay include counseling or help finding community resourcesMedical suppliesMedicare covers certain medical supplies, such as wound dressing and cathetersDurable medical equipment (DME)Medicare covers certain pieces of medical equipment, such as wheelchair or walkerOriginal Medicare covers 80% of approved amount, beneficiary may owe coinsurance Page 28Slide29
Medicare’s home health care benefit does not cover:
24-hour-per-day care at home
Prescription drugsMeals delivered to the homeHousekeeping services: light cleaning, laundry, and meal preparationHome health aides may perform housekeeping services during visit for other health-related services, but cannot visit with sole purpose of performing housekeeping dutiesHome health excluded services Page 29
24-hour care
Excluded services:Slide30
Home health care beneficiary rights
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Home health agencies
HHAs can:
Choose their patientsRefuse to take patient if they do not believe they can ensure patient’s safetyLimit kinds of services they provide and types of conditions they will care forBeneficiaries have a right to home careMedicare should cover medically necessary home care when beneficiary qualifiesOriginal Medicare beneficiaries can call 1-800-MEDICARE for help finding Medicare-certified HHA Page 31Slide32
Chronic care needs
Medicare should cover individual eligible for home health care regardless of whether condition is temporary or chronic
Skilled nursing or therapy services must be necessary to:Help individual maintain ability to functionHelp individual regain function or improveOr, prevent or slow worsening of individual’s conditionMedicare should not deny medically necessary care that maintains individual’s condition or slows deterioration Remember: HHA may choose to refuse to take patient. Beneficiaries should call 1-800-MEDICARE or Medicare Advantage Plan for assistance finding HHA. Page 32Slide33
Out-of-network HHA agency
Medicare Advantage Plans must provide members with home health care if the beneficiary’s doctor says it is medically necessary
Plans must pay for care received from an out-of-network HHA if no in-network agencies will take the individualBeneficiaries should speak to their plan about HHA options first if they cannot find an in-network HHA Page 33Slide34
When care is reduced
HHAs must give Original Medicare beneficiaries written notice, called a Home Health Advance Beneficiary Notice (HHABN), if they are reducing care
Notice explains why services are being reducedHHA may believe Medicare will no longer cover these servicesHHABN explains that beneficiaries have three options:Request care and ask SNF or HHA to bill Medicare (demand bill)Request care but agree to pay out-of-pocketOr, turn down care and look for another HHA that might cover itBeneficiary is not responsible for cost if If an HHA fails to send a beneficiary a HHABN and Medicare denies coverage for care, the beneficiary is not responsible for the cost Page 34Slide35
Demand bill
Beneficiary has right to demand bill if their care is being reduced because their HHA does not believe Medicare will cover it
HHA will bill Medicare for services supplied to beneficiaryHHAs can bill beneficiaries for home health services while Medicare makes its decisionThere are situations when individual may receive HHABN but does not have the right to request demand billIf doctor changes amount of care in beneficiary’s plan of care, beneficiary can either:Ask doctor to change plan of careFind new doctor to certify that same amount of care is necessaryForgo these servicesIf HHA reduces care for staffing or safety reasons, beneficiary can either find another HHA or forgo services Page 35Slide36
Appealing
If Original Medicare denies coverage after demand bill, beneficiary can file appeal
Original Medicare beneficiaries should follow the typical process if health service or item is denied, starting with redetermination requestBeneficiaries in Medicare Advantage Plans typically have right to appeal if their HHA is reducing services*Beneficiaries can request fast (expedited) review of this decision Page 36Slide37
Conclusion
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What you have learned
Medicare basics
Home health basics and Original Medicare’s eligibility requirements for coverageServices covered under home health benefitBeneficiary rights when receiving home health care Page 38Slide39
Resources for information and help
State Health Insurance Assistance Program (SHIP)
www.shiptacenter.org www.eldercare.gov Social Security Administration800-772-1213 www.ssa.gov Medicare1-800-MEDICARE (633-4227)www.medicare.govMedicare Rights Center800-333-4114www.medicareinteractive.org National Council on Agingwww.ncoa.org www.centerforbenefits.org
www.mymedicarematters.org
www.benefitscheckup.org
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Medicare Interactive
www.medicareinteractive.org
Web-based compendium developed by Medicare Rights for use as a look-up guide and counseling tool to help people with MedicareEasy to navigateClear, simple languageAnswers to Medicare questions and questions about related topics3+ million annual visits Page 40Slide41
Medicare Interactive Pro (MI Pro)
Web-based curriculum that empowers professionals to better help clients, patients, employees, retirees, and others navigate Medicare
Four levels with four to five courses each Quizzes and downloadable course materialsBuilds on 25 years of Medicare Rights Center counseling experienceFor details, visit www.medicareinteractive.org/learning-center/courses or contact Jay Johnson at 212-204-6234 or jjohnson@medicarerights.org Page 41