Medicare Nursing Home Coverage
Medicare Part A & B is now the health insurance plan for all eligible individuals age 65 and older and certain younger disabled persons.. Because of its universal availability almost everyone over age 65 in this country is covered by Medicare. There are about 40 million Medicare beneficiaries nationwide.
Medicare will pay for 20 days of a skilled nursing care facility at full cost and the difference between the amount above $114 (2005) per day and the actual cost for another 80 days. Private Medicare supplement insurance usually pays the 80 days of $114 per day if a person carries this insurance and the right policy form. However, Medicare often stops paying before reaching the full 100 days. When Medicare stops, so does the supplement coverage. The average paid Medicare nursing home stay was 23 days in 1997, only 1/5 of the allowable time. Nationwide, Medicare paid 12% of nursing home receipts in 1998.
To qualify for Medicare nursing home coverage, the individual must spend at least 3 full days in a hospital and must have a skilled nursing need and have a doctor order it. The transfer from a hospital must occur within a certain time period.
There is a misconception that Medicare automatically covers up to 100 days of most nursing home stays. . Even though a large number of nursing home admissions come from hospitals, not all of these receive Medicare. Many are younger than 65 and not on Medicare. For those over 65, a hospital stay resulting in nursing home care does not automatically qualify for Medicare coverage. The stay may have been less than 3 full days or there may not be a skilled need. And as has already been pointed out, even if a person qualifies for Medicare coverage it is likely to be much less than 100 days. The average coverage is about 20 days.
Home health care, instead of nursing care, is often used as an alternative for hospital patients recovering from hip or foot surgery, joint replacement or complications of diabetes. In addition, homebound patients not having spent time in a hospital, but suffering from congestive heart failure or other disabling conditions are sometimes covered with "episodes" at home.
Home care must be under a "plan of care" ordered by a doctor. There must be a skilled need requiring frequent visits by either a therapist, LPN or RN. Although allowed prior to 1997, blood draws are not covered. As part of the plan of care, aides may also be provided to help with bathing, dressing, transferring, toileting, incontinence or feeding. In addition, social services are often provided. The patient must be homebound, meaning it would be very difficult to leave the home during the period of recovery. Although, a recent ruling now allows Medicare home care patients to leave their home for therapy or treatment and still receive coverage. Medicare part B may also cover certain durable medical equipment for home care such as bed rails, walker, etc.
Prior to 1997, Medicare payments were very helpful in allowing long-term care recipients to stay at home and avoid institutions. But, Medicare was never intended to pay for chronic, long-term home care. A 1989 lawsuit asserting rights of homebound recipients as well as a lack of Medicare oversight allowed the system to get out of hand. Home health payments by Medicare increased an astounding 25% a year between 1990 and 1997, about 4 times the health care inflation rate.
In 1996, Congress passed the Balanced Budget Act and along with the Health Insurance Portability and Accountability Act of the same year, access to Medicare home health was restricted and the intent of only covering acute-care recovering patients was reasserted by these Acts.
In November 1997, under BBA, Medicare adopted an interim payment system based on a projected 1999 implementation of a Prospective Payment System for home care. PPS greatly restricted eligibility and reimbursements for homebound patients. Medicare home health benefits went from a high of $18.3 billion in 1997 to $9.5 billion in 1999, a drop almost in half. At the same time demand for covering more home care patients increased. After 1997, the number of home health agencies fell by a large amount almost overnight. Home health was 8.8% of Medicare's budget in 1997. In 1999 it was 4.6% of the budget. Medicare paid 35.6% of home health costs in 1998.
Under Prospective Payment, a health agency is only reimbursed per patient for each 60 day episode. This does not mean care can be less or more than 60 days since the agency can schedule visits until the prospective payment runs out. There are provisions to cut off reimbursement if the patient recovers early, or to extend payment if the condition worsens. Recent complaints from the home health industry indicate that Prospective Payment is not covering actual care given.
Medicare is not now a source of help for chronic, non-improving and homebound long-term care recipients. Recently, because of pressure from home health agencies, Congress passed legislation to restore some funding to home care.
The text below was copied from the Medicare home page of the Centers for Medicare and Medicaid Services it can be found online at: http://www.medicare.gov/Nursing/Alternatives.asp
Social Health Maintenance Organizations (S/HMO)
Current S/HMO Sites
* Kaiser Permanente, Portland Oregon
* SCAN, Long Beach California
* Elderplan, Brooklyn, New York
* Health Plan of Nevada, Las Vegas, Nevada
Program of All Inclusive Care for the Elderly (PACE)
* Be at least 55 years of age.
* Live in the PACE service area.
* Be screened by a team of doctors, nurses, and other health professionals.
* Sign and agree to the terms of the enrollment agreements.
Generally, these services are provided in an adult day health center setting, but may also include in-home and other referral services that enrollees may need. This includes such services as medical specialists, laboratory and other diagnostic services, hospital and nursing home care.
An enrollee's need is determined by PACE's medical team of care providers. PACE teams include:
* Primary care physicians and nurses.
* Physical, occupational, and recreational therapists.
* Social workers.
* Personal care attendants.
Generally, the PACE team has daily contact with their enrollees. This helps them to detect subtle changes in their enrollee's condition and they can react quickly to changing medical, functional, and psycho-social problems.
Persons enrolled in PACE also may have to pay a monthly premium, depending on their eligibility for Medicare and Medicaid.