JOEL MEKLER: Getting the inside track on home health care

More than 5 million people in the U.S. rely on Medicare for in-home care services.

Jan. 1, 2020, marked the beginning of a brand-new decade that many looked at with hope and optimism.

But as the year approaches its half way point, can things get any worse?

We’ve witnessed massive protests against racial injustice and police brutality and the outbreak of coronavirus or COVID-19 that has caused significant human suffering and major global economic disruption. Earlier this year there was the death of basketball legend Kobe Bryant, impeachment of President Trump, a string of wildfires in Australia, and deadly airplane crashes in Iran and Pakistan. What else can go wrong in the next six months?

As the COVID-19 virus storms through U.S. communities, some patients find themselves bouncing between hospitals and nursing homes. In some states, hospitals are clearing out patients who no longer need acute care to nursing homes. But nursing homes are weary of accepting patients discharged from hospitals for fear they will spread the virus around to other residents and staff.

Home health care may offer another alternative to lessen the stress of our health system during the pandemic. Currently, more than 5 million people in the U.S. rely on Medicare for in-home care services (also known as “home health care”) that may include: Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Language Pathology, Durable Medical Equipment, Medical Social Services, and Personal Care in some situations.

Qualifying for care

To qualify for Medicare home health care, a beneficiary must have:

•A face-to-face (in-person) encounter with a physician or other qualified provider;

•A physician’s order for home health care services and a plan of care;

•A normal inability to leave home (Homebound); and

•A need for part-time or intermittent skilled nursing care and/or therapy.

When a beneficiary is deemed “homebound” and there is a need for skilled nursing or therapy, they may be eligible for home health aide services which provide personal care services for less than 8 hours each day and less than 7 days each week (up to 28-35 hours when combined with skilled nursing and/or medical social services).

In response to the pandemic, some Medicare coverage rules for in-home care has changed. A beneficiary can now be considered “homebound” if their physician certifies that they cannot leave their home because they are at risk of medical complications if they go outside, or if they have a suspected or a confirmed case of the virus.

In “normal” times a physician is the only one who can order home health care services. But during the pandemic, other providers, including nurse practitioners and physician assistants, can order care, too. In addition, Medicare is also allowing home health care agencies to provide more services via telehealth, as long as the services are listed on the beneficiary’s plan of care.

Medicare will not cover 24-hour in-home care. If that’s the case, a skilled nursing facility may be more appropriate. Medicare will only cover home health when a beneficiary receives care from a Medicare-approved home health agency. If the beneficiary has original Medicare their physician may recommend a Medicare-certified home health agency. A beneficiary can also research and compare home health agencies on Medicare’s Home Health Compare website or by calling 1-800 MEDICARE (1-800-633-4227). If the beneficiary is enrolled in a Medicare Advantage Plan, they may need to use a provider in the plan’s network.

MAINTAINING BENEFITS

Once approved for home health care benefits, the home health care agency and the prescribing physician must provide specific and sufficient documentation why the beneficiary has a continuing need for skilled nursing and/or therapy. Tip: Vague phrases such as “patient tolerated treatment well,” “continue with plan of care” or “patient remains stable” is not specific enough to support Medicare coverage. As a practical matter, a beneficiary may have to accept less services than are optimum and less than is authorized under the law if the home health agency is unable or unwilling to meet all ordered services.

For Providers: If improvement is initially expected and that goal is reached or changed, obtain a new order from the prescribing physician that has new goals, if the goal now is to maintain, deter, or slow decline of a condition. Improvement is not required for coverage. Medicare-covered skilled nursing and therapy can also include care to maintain an individual’s condition or slow decline.

All Medicare beneficiaries, whether enrolled in original Medicare or a Medicare Advantage (MA) Plan, are entitled to the same home health care benefits under Medicare Parts A and/or B. Beneficiaries with original Medicare have little or no out-of-pocket costs. If durable medical equipment like a wheelchair or walker is purchased, the beneficiary will pay the Part B coinsurance of 20 percent. MA plans may impose cost-sharing (deductible, co-insurance, or co-payment) for certain home health services. Check with the MA plan for costs and coverage.

There is no legal limit on the duration of home health care as long as the beneficiary continues to meet the coverage criteria. When a home health care agency plans to terminate care, the beneficiary has a right to an expedited appeal to maintain their benefits. The home health care agency must give the beneficiary a written notice called a Notice of Medicare Non-Coverage (NOMNC) at least 2 days before all covered services will end. The NOMNC contains important information, including the beneficiary’s right to receive a detailed notice why services are ending and how to make an appeal. The beneficiary should contact their physician for supporting information. Please note that a beneficiary has appeal rights when all covered services are to end, but they have no appeal rights when home health services are reduced or terminated but other types of services are continued.

If the beneficiary has original Medicare, the home health agency must provide them with an Advanced Beneficiary Notice (ABN) when the agency feels services will be not be covered by Medicare. The agency must also give the beneficiary an ABN or a Home Health Change of Care Notice if they reduce or stop providing home health services or supplies. Both forms will give an explanation as to why and what services or supplies will be reduced or stopped. Again, it’s highly recommended the beneficiary contact their attending physician(s) in such circumstances.

An increased demand for home health care seems inevitable both during and after the pandemic. Thousands of patients recuperating from the COVID-19 virus will require rehabilitation and home health care may be a possible solution.

 (Joel Mekler is a certified senior adviser. Send him your Medicare questions at mekbab2000@verizon.net.) 

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