Helping clients understand Medicare’s home health benefit

Helping clients understand Medicare’s home health benefit

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 4

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 Advantage

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 7

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 8

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 9

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 10

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 11

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 12

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 14

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 15

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 16

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 17

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 care

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 19

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 20

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 21

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 22

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 24

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 25

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 26

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 27

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 28

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:

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 31

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 32

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 33

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 34

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 35

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 36

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 38

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 40

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