Navigating the health care system: Getting the right care at the right time- Part One
By Terre Mirsch
Navigating the health care system is often among the most challenging aspects of caregiving.
Understanding what is, and what is not, covered by health insurance plans such as Medicare, Medicaid, and private insurances is essential for informed decision making and ensuring that your loved one has access to needed care. Many are surprised to learn that traditional insurance coverage does not provide the 24-hour care that is referred to as ‘custodial’ care. Custodial care is non-medical care, or non-skilled care that assists with activities of daily living. As illness progresses, it is common that people need help with these activities including bathing, dressing, feeding, movement, toileting, or incontinence care. Sometimes, people have long term care insurance that can help pay for this care if certain criteria are met. Last week, my colleague, Patty, talked about options for full-time care including long term care in a nursing home or hiring a caregiver to assist you in your home. Thank you, Patty, for providing this valuable information.
While Medicare does not pay for custodial care, intermittent skilled care in the home may be covered for short periods of time under the home health care benefit, if eligibility criteria are met. Additionally, the Medicare Hospice Benefit provides for comprehensive care focused on comfort for those facing life-limiting illness. Most Medicaid and private insurance plans provide similar coverage guidelines. Understanding the difference between these two benefits will help you to advocate for your loved one, ensuring that your loved one receives the right care at the right time.
Home health care
Home health care services are designed to provide reasonable and necessary treatments for an illness or injury that help you and your loved one to become independent and self-sufficient in managing an acute or chronic health care condition.
In order for your loved one to receive home health care, the following eligibility criteria must be met:
- Your loved one must be under the care of a physician, and the physician must establish and regularly review the home health plan of care.
- The doctor must certify that home health services are needed, including at least one or more of the following services: skilled nursing, physical therapy, speech-language pathology, or continued occupational therapy.
- Your loved one must be homebound; meaning that leaving your home is not recommended or takes a considerable or taxing effort.
- Services can be provided on an intermittent, part-time basis.
- Care is provided by a Medicare-certified agency.
If eligibility criteria are met, services provided under the home health care benefit may include:
- Skilled nursing care by an RN, or LPN under the supervision of an RN, may include teaching you and your loved ones about medications, treatments, or your loved ones illness in order to support self-management. Skilled nursing care may also involve providing some care or treatments directly, when necessary to be provided by medical or licensed personnel.
- Physical therapy, occupational therapy, or speech-language pathology services may be covered when it is expected that your loved one’s condition will improve in a reasonable and predictable period of time, and a skilled therapist is needed to safely and effectively establish or perform a therapeutic maintenance program.
- Medical social services, when ordered by your loved one’s physician, may include assistance with social or emotional concerns, counseling, or help finding other care resources within your community.
- Home health aide services may be covered as support services for skilled nursing care, if needed as part of the care for your loved ones illness or injury. Home health aide services are not covered unless your loved one is also receiving skilled nursing or therapy services.
- Medical supplies, such as wound dressings, are covered when ordered as part of the home health plan of care.
All services must be ordered by the physician and able to be provided on an intermittent basis. For more information about Medicare home health benefits, you can refer to the official Centers for Medicare and Medicaid Services booklet. Medicare Advantage programs, Medicaid, or private insurance companies may vary with regards to eligibility or coverage guidelines.
Some home care agencies have programs designed to improve health care outcomes for particular illnesses or conditions including specialized programs for the elderly, or those with heart disease or respiratory disease. Other agencies have telemonitor services, infusion care, low vision programs, or palliative care, to name a few. It is important to research home care agencies in your area, and inquire about any special programs that may meet you and your loved ones unique care needs. You can also learn about how well an agency performs and how their patient’s rated the care they received on Home Health Compare.
Home health care services can restore health and wellness following acute medical or surgical needs. Or, for those with chronic illness, home health care services may involve assisting you and your loved one in learning to adjust to chronic illness and disability while optimizing self management of one’s illness, quality of life, and ability to remain in the home setting. However, those facing life-limiting or progressive illness may find their needs to be different than those addressed by the Home Health Benefit and may, instead, derive greater benefit from the use of hospice services. We’ll discuss hospice services and advantages of the Medicare Hospice Benefit in my next blog post.