Nearly one in every four Americans is enrolled in Medicare or Medicaid. These are the programs which provide health care for the aged, disabled, and indigent population administered by the Centers for Medicare Services (CMS). Because of its wide reach, trying to find the answers to your questions can often turn into a daunting experience.So where does one begin the search for information for his/her needs? Here are some resources that you may find beneficial in your quest for knowledge and answers.
Medicare coverage for Home Health Services is required to be provided -Medicare Home Health Services – ALS Patients
- BY LAW -
to all Medicare patients who meet the Home Health Services coverage criteria.
This document was created on March 29, 2016.
It is not intended to resolve the systemic issues and coverage improvements needed within the Medicare system. It is intended to act as a guide for ALS patients to immediately access existing Medicare benefits.
What Home Health Services (HHS) does Medicare cover?
All persons eligible for Medicare who meet Medicare home health services coverage criteria are eligible to receive a combined total of up to 35 hours maximum per week in the six home health services disciplines, including up to 28 hours per week of home health aide services. The problem encountered, however, is the Medicare-Certified Home Health Agencies do not have to accept a patient and are unlikely to do so if the patient initially requests more than 2-3 hours per week of home health aide services. It’s not profitable for them. It is, therefore, recommended a patient initially requests a minimal number of home health aide hours to ensure they are accepted. Once in the system, it is much easier to steadily increase the hours per week received during the recertification process, as it becomes more difficult for the Medicare-Certified Home Health Agency to deny coverage.
Home health services are available under Medicare for both Traditional/Original Medicare and Medicare Advantage plans and are provided to the patient in 60-day episodes. They are considered part-time and intermittent. The law requires each 60-day episode to provide and cover all six home health services, including medical supplies, which are paid on a reasonable cost basis. This includes costs incurred in the six home health services disciplines, which are:
1. Skilled nursing
2. Home health aide
3. Physical therapy
4. Speech-language pathology
5. Occupational therapy
6. Medical social services
What Is Medicare?
Medicare is the national program that serves as the primary source of health insurance for older people and many people with permanent disabilities such as ALS. The program was enacted in 1965 as Title 18 of the Social Security Act. Medicare has evolved significantly over the years; in 2003 additional major changes were made.
What Health Care Services Does Medicare Cover
Medicare works like other health insurance- it pays a portion of the cost of certain necessary medical services. Often cost sharing is required of the individual Medicare beneficiary, including premiums, deductibles and co-payments.
The Medicare program is divided into parts:
Who Is Eligible?
Social Security retirement recipients who are over 65 years old and individuals who have received Social Security disability benefits for 24 months are eligible for Medicare. In addition, individuals who receive Railroad Retirement Benefits and individuals who have End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS or "Lou Gerhig's Disease") are also eligible for Medicare.
Medicare is not a welfare program and should not be confused with Medicaid. While Medicaid is a state run health care financing program for low-income people, Medicare is a federal program and an individual's income and assets are not considerations in determining eligibility.
How Do People Enroll?
Generally, individuals who are 65 and are entitled to Social Security or Railroad Retirement benefits are automatically enrolled in Medicare Part A and Part B. Individuals must enroll in Part D and/or Part C during an "initial enrollment period," which begins three months before the eligibility month and extends three months after. For example: Jan’s Medicare eligibility date is December 1st. Her initial enrollment period starts in September, includes October, November, December, January, February, and will end in March.
An application for Social Security or Railroad Retirement will also suffice for Medicare. A separate application is not necessary. Individuals who choose to take early Social Security retirement benefits will be automatically enrolled in Medicare when they attain age 65. Those who are 65 but who delay receipt of Social Security benefits may still enroll in Medicare but must file an application. Individuals who qualify for Medicare because they have received Social Security or Railroad Retirement disability benefits for 24 months will be automatically enrolled in Medicare. Disabled persons diagnosed with ALS will be automatically enrolled in Medicare the month that disability benefits begin.
Individuals who miss the initial enrollment period must wait for a "general enrollment period' to enter Medicare Part B. The general enrollment period is the first three months of each calendar year (January 1 through March 31). Medicare Part B benefits do not begin until July of that year.
Those who want the prescription drug benefit must seek out and enroll in a Part D prescription drug plan of their choosing. Individuals can enroll or change Part D plans during the open enrollment period each year from October 15 through December 7.
Penalties apply for late enrollment under Part A, Part B, and Part D. Individuals who aren’t eligible for premium-free Part A and who did not buy Part A when first eligible may see their monthly premium go up 10%. This penalty is imposed for every month of late enrollment up to twice the number of months for which the beneficiary has failed to enroll. Under Part B, a 10% penalty is also imposed. The penalty is for each full year (12 month gap) of late enrollment. Unlike Part A, there is no end-point to the penalty under Part B. Under Part D, the penalty is a 1% addition to the Part D premium for every month the beneficiary failed to enroll after becoming eligible with no other creditable coverage. Medicare beneficiaries under age 65 who incur this penalty get one chance to have it forgiven when they turn 65 and take advantage of a second Initial Enrollment Period.
How Are Medicare Benefits Provided?
Most Medicare beneficiaries receive their benefits through Original Medicare (Parts A, B, and D). With the advent of Medicare Advantage in 1997, more types of benefit plans became available. The options include managed care plans, preferred provider organizations, private fee-for-service plans, and other options. In most parts of the country the only available Medicare Advantage options are managed care plans.
Beneficiaries can enroll in a Medicare Advantage plan during the open enrollment period. Once the choice is made, the beneficiary generally must receive all of his or her care through the plan in order to receive Medicare coverage. Beneficiaries can change to a different plan during the annual open enrollment period. As many changes as necessary can be made during the open enrollment period, with the coverage choice taking effect January 1.
Medicare Advantage is different from the traditional Medicare "fee-for-service" system but coverage should be the same or better. Often a Medicare managed care plan administers the health care treatment of an enrollee by the use of a physician (known as a "gatekeeper") who must approve the patient's referral to specialized care. Some Medicare managed care plans permit beneficiaries to go directly to a specialized care provider, without the gatekeeper's approval, in return for payment of an extra premium.
What Are States Pharmacuetical Assistance Programs?
Some states have their own state legislated and administered programs that provide assistance with the cost of prescription drugs, usually for individuals who meet certain income guidelines.
Can People With ALS & Other Long Term Illnesses Receive Medicare Coverage?
There is a long-standing myth that people with long-term illnesses and those in need of long-term care are not covered by Medicare. This is not true. Unfortunately, beneficiaries are too often denied Medicare coverage for a variety of services on the grounds that they have a chronic or stable condition, that their condition will not improve, and/or that the services are to maintain, not to improve, their condition. In fact, a federal judge approved an agreement with the government (Jimmo vs. Sebelius) which explicitly clarifies that skilled nursing and therapy services necessary to maintain a person's condition can be covered by Medicare.
Medicare coverage determinations should be based on what is “medically necessary” and on the specific qualifying criteria for that particular health care setting and services. The Medicare Act excludes certain services from coverage, and limits others depending on the qualifying criteria in a given case. However, people should not be denied benefits for otherwise coverable services simply because they have a long-term illness such as ALS. Further, beneficiaries are legally entitled to an individualized assessment of their qualification for coverage. These assessments should be made based on valid standards for the particular services in question, not on generalized assumptions about people with similar diagnoses. This is important for people with ALS who are too often erroneously denied Medicare coverage for physical therapy, home health care, and other important and necessary services.
Is Medicare Coverage Available for Long-Term Services and Long-Term Care?
Medicare may cover some services for long periods of time. People with ALS and other chronic conditions may be eligible for physical, occupational, and speech therapy as long as the services are skilled, medically necessary, and within Medicare’s expense caps. This is so even if the services are needed to maintain the individual's condition rather than to restore prior function. In addition, while Medicare covers only a limited amount of nursing home care in limited circumstances, the Medicare home health benefit, and sometimes the hospice benefit, can be a source of long-term care and coverage for beneficiaries.
Does Medicare Cover Physical, Occupational, and Speech Therapies?
People with ALS are often denied necessary physical therapy services on the grounds that they are not going to improve. A recent court case reinforced that this is not the deciding factor in determining the right to coverage. The question for determining the right to coverage should be the skills of a therapist necessary to establish, provide, and/or supervise the services. Skilled therapy can be needed to maintain the individual's condition or to slow further deterioration; in such cases Medicare coverage may be warranted. Each person is entitled to an individualized assessment of his/her right to Medicare coverage.
For many years there has been a cap on the annual Medicare payment for physical, occupational, and speech therapy.
Does Medicare Pay For Home Health Care?
Unlike the Medicare skilled nursing facility benefit, which provides coverage for a short period of time, Medicare coverage can be available for long-term home health care if qualifying criteria are met. There is no legal limit on the duration of time for which home health coverage is available. Further, Medicare covers home health services in full, with no required deductible or co-payments from the beneficiary. Services must be medically necessary and reasonable and the following criteria must be met:
If the triggering conditions described above are met, the beneficiary is entitled to Medicare coverage for home health services. Home health services include:
Denials of Medicare home health coverage should not occur due to particular diagnoses or the fact that a patient's condition is chronic or unlikely to improve. Each patient should be provided with an individualized assessment of his or her right to coverage. Additional advocacy tips include the following:
Does Medicare Cover Skilled Nursing Home Care?
Medicare provides a limited benefit for nursing home coverage for a limited period of time. Nursing homes are referred to in Medicare as skilled nursing facilities (SNFs). The benefit is available for a short time at best—for up to 100 days during each benefit period (a benefit period begins the day a patient is admitted as an inpatient in a hospital or SNF and ends when the patient has not received inpatient care for 60 days in a row). If Medicare coverage requirements are met, the patient is entitled to full coverage of the first 20 days of SNF care. From the 21st through the 100th day, Medicare pays for all covered services except for a daily coinsurance amount ($152.00 per day in 2014). The SNF patient will not be entitled to any Medicare coverage unless he or she was hospitalized for at least three days prior to the SNF admission and, generally, was admitted to the SNF within 30 days of the hospital discharge.
There are certain requirements that must be met in order for a patient to receive Medicare coverage. These requirements include:
The benefit for SNF care is intended to cover the services generally available in a SNF:
Unfortunately, Medicare coverage is often denied to individuals who qualify under the law. In particular, beneficiaries are often denied coverage because they have certain chronic conditions such as MS, Alzheimer's disease, Parkinson's disease, or because they need nursing or therapy to maintain their condition. These are not legitimate reasons for Medicare denials of SNF care. The question to ask is does the patient need skilled nursing and/or therapy on a daily basis, not, does the patient have a particular disease or will s/he recover. Other important advocacy tips include the following:
Does Medicare Cover Hospice Care?
Hospice care is intended to provide palliative and supportive care for the terminally ill and their families rather than treatment for the underlying condition. Medicare covers two 90-day periods of hospice care followed by an unlimited number of additional periods of 60 days each.
In order to receive Medicare hospice coverage, a patient must opt into hospice coverage, and, as a consequence, out of most other Medicare coverage for treatment of the underlying terminal condition. The hospice care must generally be provided by, or under arrangement with, a Medicare-certified hospice program during each period.
To receive Medicare coverage for hospice care, the patient must be certified as terminally ill by the patient's physician and/or the hospice staff physician, and the hospice care must be part of a written plan of treatment established by the attending physician and hospice medical professionals. If coverage conditions are met, Medicare coverage can include:
What Can Be Done To Contest A Medical Denial?
Because of the size and complexity of the Medicare program and because of the desire to contain costs, Medicare coverage is often denied when it should be granted. Sometimes these denials are a result of errors; sometimes they are a result of policy that places cost containment concerns over the needs of individual beneficiaries. Additionally, up until January 2013, there was a misunderstanding by many skilled nurses and occupational, physical and speech therapists that services would not be reimbursed if a patient is not improving - often called the Medicare "Improvement Standard." A lawsuit clarified that maintenance, or lack of improvement, is not a justification for denial.
Whatever the underlying reasons for the denial, the Medicare program includes an appeals system that is designed, at least in theory, to reverse erroneous denials and to correct mistakes. If the patient's attending physician feels the care in question is medically necessary and the care is not simply excluded from Medicare coverage (e.g., hearing aids, dental care, skilled nursing facility care when there was not a prior hospital stay), the beneficiary should appeal.
What Help Is Available To People With ALS Who Have Questions About Medicare?
The Center for Medicare Advocacy is a national non-partisan, non-profit organization headquartered in Connecticut with offices in Washington, DC and throughout the country. The Center is staffed by lawyers, nurses, and paralegals who work to advance fair access to Medicare and health care.
You can also learn about Medicare, Medicare Savings Programs, related health care and health care financing topics through the the Center for Medicare Advocacy's website.
For more information, contact Medicare at 1-800-MEDICARE or visit their web site. www.medicareadvocacy.org
Courtesy of the Center for Medicare Advocacy, Inc. / Judith Stein, Esq., Executive Director