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A Word From The Owner
Owners
There`s No Place Like Home
BY: Elizabeth Verlinger, Community Education Liaison, Infinity Home Health Services
If you`re like most people, navigating the health care system today can pose a bit of a challenge. You might find yourself asking questions like: What Exactly am I entitled to under my Medicare benefit? How do I choose the best agency or facility for my needs? And, especially in these economic times - How much is this going to cost me?
Fortunately, one of the most budget friendly options today is homecare. Home Care is appropriate for seniors in many types of situations. Some receive home care following a hospitalization for a fall, or after returning home from a stay in a rehabilitation facility. Others utilize the home care benefit for education of a new diagnosis like diabetes or congestive heart failure. There are over 9,700 home care agencies in the United States today, providing care to over 3.5 million Americans. While recuperating from a knee replacement or pneumonia, nine out of ten seniors prefer home care over institutional care. Home Care Combines efficient and compassionate services with the freedom and security that seniors deserve.
Let`s talk services: home care consists of two types of care: Skilled (or Medicare Certified) and Private Pay. Skilled care is usually covered under your medical insurance or Medicare benefit, and provides Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, and Home Health Aides. Some Medicare certified companies, Such as Infinity Home Health Services, also employ Licensed Social Workers, Dieticians and Nurse Practitioners. Private Pay is a service you pay for out of pocket. Some Private Pay agencies accept the Veterans Affairs (VA) Benefit also which can be used to assist with the payment of services. Private Pay (or Private Duty) services encompass assistance with daily living. Things like laundry, cooking, transportation to and from your doctor`s visits, light housekeeping companion care and even 24 hour care are offered by non-skilled home care agencies. While skilled agencies bill your insurance, non-skilled companies usually charge an hourly rate for their services.
Under your Medicare benefit (including your third party Medicare Indemnity) home care is covered at 100% to you as long as three conditions are met: There is a change in condition, a Physicians Order is acquired and your are considered Home bound. 1) A change in condition refers to your current health status This could be something as simple as a recent observation that you`re not as steady on your feet as you once were, to something more serious like a new diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Even if you`re just not quite feeling like your usual peppy self, you are experiencing a change in condition and might benefit from home care services. 2) A physician`s order for home care could be written by your doctor in several different circumstances: upon discharge from a skilled nursing or rehabilitation center, in his or her office while examining you for a change in condition or, in most instances, upon your request. Medicare will not cover home care under Part A unless the recipient of that care is considered homebound for the duration of the care provide. The finite definition of homebound status states that trips out of the individual`s home are taxing on the individual, require great assistance and are of short duration. Simply put you may leave your home, as long as you are not driving yourself, for a few hours a few times a week. May you attend church every week? Absolutely. Trips to the beauty salon, doctors visits, birthday parties for grandchildren, etc., are all acceptable. Driving yourself to the grocery store is against the rules, as is meeting your social group for coffee at McDonalds twice a week. Again, these three conditions must be met only while you are receiving home care. Once you have met your goals and been discharged from care, you are free to come and go as you please.
Once a home care agency has determined that all three conditions are met, a Registered nurse will visit your home to provide a head to toe assessment. The nurse will obtain information such as current vital signs, current diagnosis and past medical history. Following her assessment, the nurse will use both her findings and your personal health and wellness related goals to devise a plan of care. In skilled homecare, it is important to remember that the care delivered in the home is intermittent and is only meant to assist individuals in achieving safety, knowledge and independence at home. Depending on your needs, a nurse or therapist will visit your home several times per week until you are feeling better, having met your goals. Most average home care episodes last between 18 and 21 days, or approximately 10-12 home care visits. Home care is not meant to replace the 24 hour care provided by a hospital or skilled nursing facility that is necessary in certain health related situations. You may receive skilled home care following a new diagnosis such as diabetes, renal failure or pain management following the amputation of a limb. In these situations, you home care agency will also provide education visits to ensure that you understand you diagnosis, and new or updated medication dosages or interactions, and any dietary or lifestyle changes that must take place in order for you to succeed independently at home, as well as assistance with any new or adaptive equipment that might accompany you back home.
If you are returning home from a skilled stay at the hospital, it must be determined that you are considered safe to return home. Having the proper family or social support in place to provide you with the potential to thrive independently in the community is vital. When you are given the go ahead to return home and home care is being set up for you, it is very important to remember that Medicare mandates that you have the right to choose your home care agency for both skilled and non-skilled services.
I. Guide to Medicare Coverage
Who qualifies for Medicare benefits?
•Individuals 65 years of age or older
•Individuals under 65 with permanent kidney failure (beginning three months after dialysis begins), or
•Individuals under 65, permanently disabled and entitled to Social Security benefits (beginning 24 months after the start of disability benefits)
The Different Benefits of Traditional Medicare
•Medicare Part A benefits cover hospital stays, home health care and hospice services.
•Medicare Part B benefits cover physician visits, laboratory tests, ambulance services and home medical equipment.
•While oftentimes you do not have to pay a monthly fee to have Part A benefits, the Part B program requires a monthly premium to stay enrolled. In 2008 that premium will range between $96.40 and 238.40 per month depending on your income. Typically, this amount will be taken from your Social Security check.
What Can You Expect to Pay?
•Every year, in addition to your monthly premium, you will have to pay the first $135 of covered expenses out of pocket and then 20 percent of all approved charges if the provider agrees to accept Medicare payments.
•Unfortunately, your medical equipment provider cannot automatically waive this 20 percent or your deductible without suffering penalties from Medicare. Your provider must attempt to collect the coinsurance and deductible if those charges are not covered by another insurance plan; however, certain exceptions can be made if you suffer from qualifying financial hardships.
•If you have a supplemental insurance policy, that plan may pick up this portion of your responsibility after your supplemental plans deductible has been satisfied.
•If your medical equipment provider does not accept assignment with Medicare you may be asked to pay the full price up front, but they will file a claim on your behalf to Medicare. In turn, Medicare will process the claim and mail you a check to cover a portion of your expenses if the charges are approved.
Other possible costs:
•Medicare will pay only for items that meet your basic needs. Oftentimes you will find that your provider offers a wide selection of products that vary slightly in appearance or features. You may decide that you prefer the products that offer these additional features. Your provider should give you the option to allow you to privately pay a little extra money to get the product that you really want.
•To take advantage of this opportunity, a new form has been approved by the Centers for Medicare and Medicaid Services (CMS) that allows patients to upgrade to a piece of equipment that they like better than other standard options for which they may otherwise qualify.
•The Advance Beneficiary Notice, or ABN, must detail how the products differ, and requires a signature to indicate that you agree to pay the difference in the retail costs between two similar items. Your provider will typically accept assignment on the standard product and apply that cost toward the purchase of the fancier item, thus requiring less money out of your pocket.
Purpose of ABN
•The Advance Beneficiary Notice also will be used to notify you ahead of time that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay under different circumstances. The form should be detailed enough that you understand why Medicare will probably not pay for the item you are requesting.
•The purpose of the form is to allow you to make an informed decision about whether or not to receive the item or service knowing that you may have additional out-of-pocket expenses.
Durable Medical Equipment (DME) Defined
•In order for any item to be covered under Medicare, it typically has to meet the test of durability. Medicare will pay for medical equipment when the item:
oWithstands repeated use (excludes many disposable items such as underpads)
oIs used for a medical purpose (meaning there is an underlying condition which the item should improve)
oIs useless in the absence of illness or injury (thus excluding any item preventive in nature such as bathroom safety items used to prevent injuries)
oUsed in the home (which excludes all items that are needed only when leaving the confines of the home setting)
Understanding Assignment (a claim-by-claim contract)
•When providers accept assignment, they are agreeing to accept Medicares approved amount as payment in full.
•You will be responsible for 20 percent of that approved amount. This is called your coinsurance.
•You also will be responsible for the annual deductible, which is $135.00 for 2008.
•If a provider does not accept assignment with Medicare, you will be responsible for paying the full amount upfront. The provider will still file a claim on your behalf and any reimbursement made by Medicare will be paid to you directly. (Providers must still notify you in advance, using the Advance Beneficiary Notice, if they do not believe Medicare will pay for your claim.)
Mandatory Submission of Claims
•Every provider is required to submit a claim for covered services within one year from the date of service
The role of the physician with respect to home medical equipment:
•Every item billed to Medicare requires a physicians order or a special form called a Certificate of Medical Necessity (CMN), and sometimes additional documentation will be required.
•Nurse Practitioners, Physician Assistants, Interns, Residents and Clinical Nurse Specialists can also order medical equipment and sign CMNs when they are treating a patient.
•All physicians have the right to refuse to complete documentation for equipment they did not order, so make sure you consult with your physician before requesting an item from a provider.
Prescriptions Before Delivery:
•For some items, Medicare requires your provider to have completed documentation (which is more than just a call-in order or a prescription from your doctor) before these items can be delivered to you:
oDecubitus care (wheelchair cushions and pressure-relieving surfaces placed on a hospital bed)
oSeat lift mechanisms
oTENS Units (for pain management)
oPower Operated Vehicles/Scooters
oElectric or Power Wheelchairs
oNegative Pressure Wound Therapy (wound vacs)
How does Medicare pay for and allow you to use the equipment?
1.Typically there are four ways Medicare will pay for a covered item:
oPurchase it outright; then the equipment belongs to you,
oRent it continuously until it is no longer needed, or
oConsider it a capped rental in which Medicare will rent the item for a total of 13 months and consider the item purchased after having made 13 payments.
2.Medicare will not allow you to purchase these items outright (even if you think you will need it for a long period of time).
3.This is to allow you to spread out your coinsurance instead of paying in one lump sum.
4.It also protects the Medicare program from paying too much should your needs change earlier than expected.
5.If you have oxygen therapy, Medicare will make rental payments for a total of 36 months during which time this fee covers all service, accessories, and oxygen contents.
6.Beyond the 36 months, Medicare will limit payments to replacement of accessories, and allows a small fee for monthly content and to check the equipment every six months.
7.After an item has been purchased for you, you will be responsible for calling your provider any time that item needs to be serviced or repaired. When necessary, Medicare will pay for a portion of repairs, labor, replacement parts, and for temporary loaner equipment to use during the time your product is in for servicing. All of this is contingent on the fact that you still need the item at the time of repair and continue to meet Medicares coverage criteria for the item being repaired.
It is with extreme pride that I share just what makes Infinity Home Health Services unique among the current, often confusing homecare environment. Infinity Home Health Services was started thirteen years ago by nurses including myself, and continues to be managed by clinicians. We pride ourselves in assuring that our patients always come first. Every member of the Infinity team is committed to achieving our mission of providing high quality, client centered health every day. Customer service is our priority.
Our entire staff is dedicated and caring. We educate and advocate for our clients' welfare and safety. We maintain an ethical and professional environment, while conveying a personable and family-like attitude. We welcome the opportunity to care for you or your loved ones. It is our pleasure and distinct privilege to be of service to those living in our community.
Sincerely,
Administrator
Main Office:
Westpoint Corporate Center
868 Corporate Way
westlake, Ohio 44145
Office: 440 -614 -0145
Fax: 440.-614-0149
Referrals: 888-804-8778
The HomeCare Elite™ is the definitive compilation of the most successful Medicare-certified home health care providers in the U.S. This review recognizes the Top 25 percent of agencies based on an analysis of quality outcomes, quality improvement, and financial performance.
