Is home health care affected?
The agreement might have a major impact on seniors with chronic illnesses who want to remain in their homes by ensuring that Medicare covers skilled care there. These services include therapy, mental health counseling and nursing care. To be eligible, Medicare requires that the patient be homebound although not necessarily confined to bed. Visiting nurses are covered for services at home, including administering intravenous drugs or wound care. There is no time limit for home care if the amount of skilled care is reasonable and not given daily, if it is provided by a trained professional and if the patient has a doctor’s order indicating that treatment is medically necessary.
Medicare pays for part-time home health aides to provide assistance with dressing, eating and other daily living activities, but only for patients who also receive skilled care at home. Medicare doesn’t pay for care from friends or family members.
What does the agreement say about nursing home coverage?
It states that skilled nursing services are covered when “necessary to maintain the patient’s current condition or prevent or slow further deterioration.”
Other requirements for nursing home coverage still apply: Nursing services or therapy must be based on a patient’s clinical condition and be provided by a registered nurse, licensed practical nurse or therapist. Beneficiaries qualify only after having spent at least three days in the hospital as an inpatient. (Observation hospital stays don’t count.)
Medicare will cover up to 100 days in a nursing home per “benefit period,” which starts when a beneficiary enters the hospital or a nursing home for skilled care and ends 60 days after the skilled care has been discontinued.
What about nursing home residents in long-term care who have used up their 100 days and pay
out of their own pockets?
Seniors can still get skilled care even if they are not improving and have used up their 100 days of nursing home coverage. Even if residents do not qualify for Medicare for their stay in the nursing home, Medicare may cover physical therapy and other skilled care for those who meet the requirements for outpatient therapy. The $1,900 outpatient therapy caps would also apply.
Will Medicare reimburse people who were denied coverage due to a lack of improvement?
Yes, a special review process will be set up for patients whose claims were denied after the lawsuit was filed on Jan. 18, 2011.
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.