With many of us living active lifestyles well into our golden years, we’re never fully ready to be sidetracked by an injury or illness. Unfortunately, the unexpected can happen at any time and being prepared for the cost, care and logistics that come with a health setback can make recovery a little less painful.
According to the National Association for Home Care and Hospice, 12 million people in the U.S. will require home health care in 2019.
But not all of them are eligible for reimbursement under Medicaid or Medicare, whether it’s because the home care they need does not fall under the insurance guidelines or because they fail to follow the proper steps to get qualified.
As one of the top home health care St. Louis providers, Envision Health Partners is dedicated to unraveling the complexities of Medicare and Medicaid eligibility for our patients. From the moment you need us, we’ll work with your medical team, therapists and insurance companies to help you get the maximum level of care you’re entitled to.
But before that day even arrives, we’re here to explain the four biggest senior health care eligibility concerns we hear from our patients.
What health conditions qualify for home health care?
Home health care covers a variety of acute health issues that seniors face. Depending on the severity of the illness or injury, a stay in a nursing home or rehab center may be the best option for recovery. But in many cases, a patient can recuperate faster and with less pain while in the comfort and convenience of home.
For example, home health care providers like Envision can offer physical therapy to get you up and moving after breaking a bone or falling down the stairs. If you suffer a stroke or a serious illness, speech and occupational therapy are available to get you back to where you want to be. Or, you can receive wound care and injections following surgery.
While the needs for senior health care may vary, there are four main requirements those age 65 and older (or those who become disabled) must meet to be eligible for home health care benefits under Medicare Plan A guidelines, according to the National Council on Aging:
- You must be considered homebound based on Centers for Medicare & Medicaid criteria, meaning that because of your condition, you cannot receive treatment outside the home without assistance, such as special transportation or help from family members. However, your condition is not severe enough to require around-the-clock care.
- You require part-time or intermittent care from a skilled nurse or therapist to improve or maintain your health or to prevent your condition from declining further. Intermittent care refers to care given fewer than seven days a week and daily for less than eight hours each day for up to three weeks (though an extension can be approved in exceptional circumstances).
- Your healthcare provider documents a plan of care that certifies you as homebound and outlines the services and equipment you will need for your recovery. The plan will need to be regularly reviewed by your provider.
- You receive services from a Medicare-approved home health care provider like Envision.
Because adherence to the care plan is so critical for Medicare reimbursements, your team at Envision will stay in regular contact with your medical team to ensure your healthcare goals are met, and if they’re not, will determine what modifications can be made to help you live independently in your own home for as long as you can.
What eligible senior health care services will Medicare pay for?
Today, Medicare is the largest single payer of home health care services for seniors, with reimbursements totaling 41 percent of overall expenditures. Seniors who are enrolled in Medicare Plan A and qualify for services can expect to pay nothing for the home health care they need.
However, the home health care services approved by Medicare are limited to skilled medical care. These include:
- Professional nursing care delivered by a registered nurse (RN) or a licensed practical nurse. These can include but are not limited to, changing wound dressings, administering IV drugs or injections, tube feedings, or prescription education.
- Physical, speech or occupational therapy to restore, improve or maintain your functionality after a fall, stroke, heart attack, surgery, or another acute health setback.
- Medical social services that address social or emotional concerns you have or help you navigate resources in your community. However, social services are only covered if you’re also receiving skilled nursing care at home.
- Certified nurse assistants (CNA) who can monitor your health and assist you with basic personal services. Like medical social workers, CNAs can only work in your home if you have a medical care plan.
- Dietary consultants who can develop meal plans for conditions like diabetes and heart disease and assist patients with preparation tips and food selection.
- Medical supplies, such as wound dressings and blood sugar test strips. If a doctor requires more durable equipment, like a wheelchair, walker or lift bed, you may be responsible for 20 percent of the
- Medicare-approved cost. Medical equipment is covered under Medicare Plan B as opposed to Plan A.
Before any treatment begins at home, Envision will ensure that the services we deliver meet Medicare’s qualifications for eligibility. If they do not, we can discuss other options to help cover costs, such as private insurance or Medicaid.
My treatment is over, but I still need help with basic personal care, like grooming and bathing. Are these services Medicare-eligible?
As previously mentioned, Medicare care will pay for home health aide services, such as dressing, transportation and meal preparation, to assist you through your recovery but only if done in conjunction with skilled nursing or therapy services. Once your healthcare provider releases you from home health care, payment for personal care ends along with medical care.
Thankfully, senior health care patients in St. Louis and St. Charles have options to assist with the costs of non-medical care. Many private insurances cover long-term or custodial care, but for those without supplemental insurance or on limited incomes, a state-based Medicaid Independent Living Waiver program eases the cost of care. The waiver can pay for deductibles and copayments that remain after Medicare reimbursements and assist with home health costs.
Missouri’s Medicaid program, MO HealthNet, looks at two eligibility requirements – your medical need and your financial need. As with skilled nursing services, a doctor’s order or evaluation is required to determine if your current health condition leaves you 1) homebound, and 2) unable to manage basic daily activities, like cooking and cleaning, by yourself. Furthermore, you must be authorized by the Missouri State Department of Health and Senior Services for homemaker or respite care services.
In terms of financial need, every state’s requirements are different, but they all look at one’s income and assets. In Missouri, as of January 2018, if you are age 63 or older, have a monthly income at or below $1,311, and require a level of personal care provided by a traditional nursing facility, you can apply for an Aged and Disabled Waiver to remain in your home.
Home care services covered by an HCBS waiver include:
- Basic housekeeping
- Laundry services
- Bathing, dressing and personal hygiene
- Meal preparation or deliver
- Respite care
- Home modifications
- Transportation to and from appointments
- Adult day care
In addition, your Medicaid-eligible home care team may include certified nurse assistants and home health aides who can monitor your health condition, including your medication compliance, physical exercise and mobility, and vital signs.
There are a number of factors that can impact your Medicaid eligibility, such as home ownership, marriage or divorce, and financial investments. Or, if you move from Missouri to a different state, you may not qualify for your current benefits as eligibility varies from state to state. If you’re receiving skilled nursing care through Medicare, ask to speak with a medical social services provider who can explain qualifications for home care or discuss your concerns with an elder law attorney.
How can home health care providers like Envision help me decode my eligibility?
At Envision, we encourage all seniors and their family members to research Medicaid and Medicare qualification guidelines before an illness or injury happens. By determining your eligibility now, you and your financial planner can establish a strategy that will assist with home care costs in the event you’re unable to manage your daily living activities. Or, if you qualify for the Medicare Independent Living Waiver, you can keep an eye on any changes in income that may affect your eligibility.
When home health care is on the horizon, Envision serves as your advocate, partner, and supporter. We’ll inform you immediately what services do and do not qualify for Medicare reimbursement, and work with you to find the best option for your needs at every step in the recovery process and beyond. In addition, we’ll perform an extensive evaluation of your care needs and work directly with your medical provider to deliver skilled services that maximize your health outcomes.
The Envision home health care team is available Monday through Friday to answer your insurance eligibility questions, and if you’re ready, schedule you for a one-on-one health assessment to discuss your current health needs. Together, we can help you focus on your recovery instead of the financial costs that may come with it.