Helping clients understand Medicare’s home health benefit

1. Helping clients understand Medicare’s home health benefit

2. Medicare Rights Center 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

3. National Council on Aging 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 the National 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.

4. Learning objectives • Understand Medicare basics • Outline home health basics and Original Medicare’s eligibility requirements for coverage • Review services covered under home health benefit • Know how to counsel clients about their rights when receiving home health care

5. Medicare basics

6. 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 time • Those under 65 with kidney failure requiring dialysis or transplant • No income requirements • Two ways to receive Medicare benefits Original Medicare Medicare Advantage Traditional program offered directly through federal government Private plans that contract with federal government to provide Medicare benefits

7. Medicare eligibility – 65+ • After turning 65, individual qualifies for Medicare if they • Collect or qualify to collect Social Security or Railroad Retirement benefits • OR are a current U.S. resident and either • A U.S. citizen • OR a permanent resident having lived in the U.S. for five years in a row before applying for Medicare

8. 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 SSDI • OR, they have End-Stage Renal Disease (ESRD or kidney failure), and they or a family member have enough Medicare work history

9. Parts of Medicare • Medicare benefits administered in three parts • Part A – Hospital/inpatient benefits • Part B – Doctor/outpatient benefits • Part D – Prescription drug benefit • Original Medicare includes Part A and Part B • Part D benefit offered through stand-alone prescription drug plan • What happened to Part C?  Medicare Advantage Plans (MA Plans) • Way to get Parts A, B, and D through one private plan • Administered by private insurance companies that contract with federal government • Not a separate benefit: everyone with Medicare Advantage still has Medicare

10. Part A-covered services • Inpatient hospital care • Care provided to individual formally admitted into the hospital by attending physician • Inpatient skilled nursing facility care • Short-term, post-hospital extended care at lower level of care than inpatient hospital care • Home health care • Care to treat illness or injury in the home • Often provided by licensed nurse or therapist, including therapy, skilled nursing, and personal care (if skilled care also required) • Hospice care • Comprehensive care for people who are terminally ill

11. Part B-covered services • Physicians’ services • Medically necessary services provided to individual by doctor on outpatient basis • Emergency room visits • Preventive care • Care intended to detect and prevent illness or keep beneficiary healthy, such as cancer screenings • Home health care • Durable medical equipment (DME) • Equipment that serves medical purpose, is able to withstand repeated use, and is appropriate for use in home • Emergency ambulance transportation (in very limited cases)

12. Medicare excluded services • Most dental care • Most vision care • Routine hearing care • Most foot care • Most long-term care • Alternative medicine • Most care received outside the U.S. • Personal care if there is no need for skilled care • Most non-emergency transportation Note: Medicare Advantage Plans (or Medicaid if beneficiary qualifies) may cover these services

13. Home health basics

14. 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 care • Original Medicare pays in full for most services* • At minimum, Medicare Advantage Plans must provide same level of home health care as Original Medicare • May impose different rules, restrictions, and costs

15. Coverage requirements • Original Medicare covers home health services if: • Beneficiary is homebound • Beneficiary needs skilled nursing services and/or skilled therapy on an intermittent basis • Beneficiary has face-to-face meeting with doctor • Beneficiary’s doctor signs home health certification confirming that beneficiary is homebound and needs skilled care • And, beneficiary receives care from a Medicare-certified home health agency

16. 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 home • And, it is difficult for them to leave home and they typically cannot do so • Doctor must evaluate individual’s condition and certify that they are homebound Beneficiary 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.

17. Intermittent care • 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 finite • Individual must require skilled nursing of skilled therapy on intermittent basis to qualify for home health

18. Face-to-face meeting • Beneficiary required to have face-to-face meeting with doctor either: • Following qualify as face-to-face meeting: • Office visit • Hospital visit • In certain circumstances, meeting facilitated by technology (such as video conferencing) • Within 90 days before starting home care • Or, 30 days after first day individual receives care

19. Home health certification • Beneficiary’s doctor must sign home health certification confirming that: • Beneficiary is homebound • Beneficiary needs intermittent skilled nursing or therapy services • Doctor has approved plan of care for beneficiary • Face-to-face meeting requirement was met • Doctor should review and certify home health plan every 60 days • Face-to-face meeting not required for recertification

20. 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 needs • Frequency individual will receive services • Predicted outcomes of treatment • Doctor must sign plan of care • Initial plan of care and home health certification lasts 60 days • Both can be renewed for as many 60-day periods as necessary, as long as doctor continues to sign • Beneficiary should speak to their provider to suggest modifications to plan of care

21. 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 B • Part 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 SNF If beneficiary does not meet Part A coverage requirements, their home health services will be covered under Part B

22. Medicare Advantage home health coverage • Medicare Advantage Plans must follow Original Medicare’s rules for providing care, but can impose different network rules, restrictions, and costs • Plan may require: • Beneficiary uses in-network HHA • Prior authorization or referral before covering care • Copayment for care

23. Home health care-covered services

24. Skilled nursing care • Services performed by or under supervision of licensed or certified nurse • Includes: • Injections • Tube feedings • Catheter changes • Wound care • Observation and assessment of beneficiary’s condition • Management and evaluation of beneficiary’s plan of care

25. 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

26. 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)

27. 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 week • In some circumstances, up to 35 hours per week • Includes activities such as: • Bathing • Toileting • Dressing • Medicare does not pay for aide if individual does not need skilled care

28. Other home health services • Medical social services • Medicare covers services ordered by doctor to help individual with social and emotional concerns related to illness • May include counseling or help finding community resources • Medical supplies • Medicare covers certain medical supplies, such as wound dressing and catheters • Durable medical equipment (DME) • Medicare covers certain pieces of medical equipment, such as wheelchair or walker • Original Medicare covers 80% of approved amount, beneficiary may owe coinsurance

29. Home health excluded services • Medicare’s home health care benefit does not cover: • 24-hour-per-day care at home • Prescription drugs • Meals delivered to the home • Housekeeping services: light cleaning, laundry, and meal preparation • Home health aides may perform housekeeping services during visit for other health-related services, but cannot visit with sole purpose of performing housekeeping duties Excluded services: 24-hour care

30. Home health care beneficiary rights

31. Home health agencies • HHAs can: • Choose their patients • Refuse to take patient if they do not believe they can ensure patient’s safety • Limit kinds of services they provide and types of conditions they will care for • Beneficiaries have a right to home care • Medicare should cover medically necessary home care when beneficiary qualifies • Original Medicare beneficiaries can call 1-800-MEDICARE for help finding Medicare-certified HHA

32. 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 function • Help individual regain function or improve • Or, prevent or slow worsening of individual’s condition • Medicare 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.

33. 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 individual • Beneficiaries should speak to their plan about HHA options first if they cannot find an in-network HHA

34. 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 reduced • HHA may believe Medicare will no longer cover these services • HHABN 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-pocket • Or, turn down care and look for another HHA that might cover it • Beneficiary 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

35. 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 beneficiary • HHAs can bill beneficiaries for home health services while Medicare makes its decision • There are situations when individual may receive HHABN but does not have the right to request demand bill • If doctor changes amount of care in beneficiary’s plan of care, beneficiary can either: • Ask doctor to change plan of care • Find new doctor to certify that same amount of care is necessary • Forgo these services • If HHA reduces care for staffing or safety reasons, beneficiary can either find another HHA or forgo services

36. 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 request • Beneficiaries in Medicare Advantage Plans typically have right to appeal if their HHA is reducing services* • Beneficiaries can request fast (expedited) review of this decision

37. Conclusion

38. What you have learned • Medicare basics • Home health basics and Original Medicare’s eligibility requirements for coverage • Services covered under home health benefit • Beneficiary rights when receiving home health care

39. Resources for information and help • Medicare Rights Center • 800-333-4114 • www.medicareinteractive.org • National Council on Aging • www.ncoa.org • www.centerforbenefits.org • www.mymedicarematters.org • www.benefitscheckup.org State Health Insurance Assistance Program (SHIP) • www.shiptacenter.org • www.eldercare.gov Social Security Administration • 800-772-1213 • www.ssa.gov Medicare • 1-800-MEDICARE (633-4227) • www.medicare.gov

40. 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 Medicare • Easy to navigate • Clear, simple language • Answers to Medicare questions and questions about related topics • 3+ million annual visits

41. 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 materials • Builds on 25 years of Medicare Rights Center counseling experience • For details, visit www.medicareinteractive.org/learning-center/courses or contact Jay Johnson at 212-204-6234 or jjohnson@medicarerights.org