Home Health Services Coverage

Table of Content

• What kind of care do I need?
• Senior Care Options: Nursing Home Costs And Ratings For Medicare And Medicaid Insurance
• Medicare nursing home coverage
• Qualifying When Youre Over Medicaid Financial Limits
• Which Medicare plans may be best if you need nursing home care in the next year?
• New York attorney general sues nursing home for alleged $22.6M Medicaid, Medicare fraud scheme

This helps you and the home health agency know earlier in the process if Medicare is likely to cover the services. Medicare will review the information and cover the services if the services are medically necessary and meet Medicare requirements. Medicare coverage for nursing home care is limited to 100 days and the patient must be receiving skilled care for recovery after an inpatient hospitalization. In the absence of any other public program covering long-term care , Medicaid has become the default nursing home insurance of the middle class. Lacking access to alternatives such as paying privately or being covered by a long-term care insurance policy, most people pay out of their own pockets for long-term care until they become eligible for Medicaid. Many seniors and their families search for ways to make long-term care more affordable.

For example, each state sets its own income limit to determine if you are eligible for Medicaid. Not all nursing homes accept Medicaid, so check with each facility. Medicare and Medicaid may offer some coverage for nursing homes, but many people don't realize they do not cover 100 percent of the cost for everyone. Each program pays for different care types, and both have specific eligibility requirements, even for older adults over 65. This article untangles the differences between Medicare and Medicaid nursing home coverage, what they each pay for, and how to qualify.

What kind of care do I need?

Medicare does not cover nursing home care—because it doesn't cover custodial care. For qualifying individuals, Medicaid picks up most of the tab for nursing home care, paying an average of 45 percent to 65 percent. However, coverage is largely dependent on a variety of factors such as financial status, the state you reside in, and the level of care needed. Your home health agency, which will work with you during this time, can also tell you which services Medicare covers and to what extent.

Then a Medicare-certified home health care agency will help coordinate your care. Services can vary, but may include help to go to the bathroom, assistance getting medications, and meal services. Usually, a home health care agency coordinates the services your doctor orders for you. In New York, it is never too late to save assets from nursing home costs. If a married couple has too many assets to qualify for Medicaid in a nursing home, the law of spousal refusal allows the spouse at home to “refuse” to pay the nursing home, which can save substantial assets.

Senior Care Options: Nursing Home Costs And Ratings For Medicare And Medicaid Insurance

Medicare covers your home health services over a 60-day period, after which the doctor must review your plan of care. However, there is no limit to the number of times your doctor can reorder this care for you, as long as it remains medically necessary to treat your condition. NoteIf you get services from a home health agency in Florida, Illinois, Massachusetts, Michigan, or Texas, you may be affected by a Medicare demonstration program. Under this demonstration, your home health agency, or you, may submit a request for pre-claim review of coverage for home health services to Medicare.

The exact services that Medicaid covers will vary by state and the specific program a senior enrolls in. All states offer some degree of personal care services , but the ways in which they are administered differ widely. For example, some state Medicaid programs provide eligible seniors with personal care assistance but not in an assisted living residence.

Medicare nursing home coverage

Care in an assisted living facility costs on average $48,612 per year, a 68.79 percent increase from 2004. Some individuals may find they require Medicaid services after they exhaust their personal financial resources in paying for long-term care. To find out more on how to qualify, visit the State Health Insurance Assistance Programs network.

These services are also covered under Medicare Advantage — a Medicare-approved plan run by private insurance companies. “If it’s a benefit that’s offered under Original Medicare, it has to be offered under Medicare Advantage too,” says Miller. Medicaid, the insurance program that helps cover costs for those in low-income households, has state and national programs that help pay for nursing home care.

Nursing home care often allows a person to live independently without having to engage in home maintenance activities, like mowing the lawn or upkeep on a home. If a person lives in a nursing home, they’ll typically receive their prescriptions from a long-term care pharmacy that provides medications to those in long-term care facilities like a nursing home. Your doctor must determine that your condition will improve, and that your need for home health services is temporary. Your Medicare home health services benefits aren't changing and your access to home health services shouldn’t be delayed by the pre-claim review process.

For example, commonly an individual will enter a Medicare SNF following a hospitalization that qualifies him or her for a limited period of SNF services. If nursing home services are still required after the period of SNF coverage, the individual may pay privately, and use any long-term care insurance they may have. If the nursing home is not Medicaid certified, he or she would have to transfer to a NF to be covered by the Medicaid NF benefit. To be eligible for Medicare nursing home coverage you must have first had a qualifying hospital stay.

Medicare Part A covers some specific, short-term services within a skilled nursing facility if deemed medically necessary. For example, it may cover skilled treatment for an injury or illness in a nursing home. Medicaid is a federal program available to people from low-income households. Medicaid can help cover nursing home costs for people who meet the eligibility criteria. Medicaid will cover 100% of nursing home costs in most cases if you meet eligibility requirements including skilled nursing care, rehabilitation, and long-term care at a nursing home. Medicare coverage for in-home nursing care doesn’t usually include meals, homemaker services, or round-the-clock nursing.

Medicaid does help you keep a small sum of money reserved for your own personal allowance to cover other expenses. However, most of it is for covering the cost of your nursing home room and board via Medicaid. Here are a few tips for finding the right nursing home for your needs.If you like your doctor, ask if they provide services for any local nursing homes. In the event that you find out the nursing home is not Medicaid-certified, you would have to transfer to a nursing facility thats covered by Medicaid. If you’re a resident of one of these states, you might want to request a pre-claim review as soon as your doctor orders your home health care.

Medicare also has helpful resources to help you find nursing homes that accept Medicare in your area. Nursing Home Compare allows consumers to compare information about nursing homes. It contains quality of care and staffing information for all 15,000 plus Medicare- and Medicaid-participating nursing homes.

Some companies offer SNPs to every Medicare beneficiary in a given state; others limit availability to certain counties. Also, one company could have multiple SNPs for you to choose from, while another may only provide a single plan. This also applies to certain “substantive coverage criteria and benefit conditions” that are not governed by an NCD or LCD, including transfers to post-acute settings. For better and for worse, Medicaid is the primary method of paying for nursing home care in the United States.

Many people start off paying for nursing home care with their savings and/or through LTC insurance. Even with Medicaid, Medicare, and private insurance, many people end up paying for at least some nursing home expenses out of pocket. Most long-term care happens at home from family, friends, and caregivers.