Most of us understand how Medicare works and pays for a hospitalization and going to the Doctor’s office for visits. We even have a pretty good understanding of how to use our insurance to get labs drawn, x-rays, MRIs or go to the ER. What can sometimes be confusing is how Medicare works in areas of Post Acute Care. As we age and/or have multiple complicated conditions, we may need ongoing care after a serious illness, surgery or hospital stay. Post Acute Care encompasses home health care, home or outpatient therapy, hospice care or skilled rehabilitation. Let’s take a deeper dive into those services and what to expect in terms of Medicare coverage.
Home Health Care
This can be recommended after a hospital stay or sometimes even through your Doctor at an office visit if you are starting to have some issues maintaining function at home. Home Health Care is a Medicare covered service and can include home visits by a Nurse, Nurse Aide, PT, OT, Speech Therapy and even Social Workers. However, there are some limitations. It is most definitely not 24-hour care/supervision or custodial care. Medicare only pays for what is called ‘skilled’ care. This means there is an active problem or diagnosis requiring intervention. A Nurse will be continually assessing and/or applying treatments. He or she will be adjusting medications and reporting back to the Doctor. Therapists will have goals, and the patient must participate and show progress. These are required for Medicare to continue to pay. Medicare also only covers 80% of all visits. There will be copays or coinsurance for each visit. Home Health Care is short term. This is not a service that Medicare will pay for in the long term. Once goals are met or a patient is no longer participating or needs to be assessed, the services will cease. Any ongoing care of a loved one at home will be paid privately out of pocket or by state funding for low-income individuals.
Outpatient Therapy
This type of Post Acute Care is pretty self-explanatory. If you are physically able to move and travel, Outpatient Therapy may be recommended. You can only qualify for Home Health Care is you are considered ‘home-bound’ or unable to travel. For Outpatient Therapy, you will go to a location and have therapy sessions that are ordered by a Doctor as you rehabilitate and get stronger post illness, surgery or hospitalization. The same rules above apply for Medicare coverage including copays and coinsurance with each visit. And again, once goals have been met, services will cease.
Inpatient Rehabilitation
This route is a more intense version of the above two. You can receive inpatient rehabilitation in a free standing rehab hospital or within a wing of a Skilled Nursing Facility or Nursing Home. Most have a separate wing dedicated to intense rehabilitative care. There are much more intense and longer therapy sessions and round the clock nursing care. To qualify, you have to be too unstable to continue recovering at home but stable enough to need removed from the hospital inpatient bed. Medicare pays for the stay and services on a short-term basis and requires frequent updates from the Interdisciplinary Team. If you have an Advantage Plan, there is more oversight and real time review of the updates to justify coverage. With Original Medicare, the same rules apply, however, CMS does not have the resources to enforce it in real time. If you want more details on this, check out my previous blog on how to manage your stay in Nursing Home Rehab. [https://www.cdi-cares.com/blog/navigating-nursing-home-rehab-on-an-advantage-plan]
Hospice Care
There comes a point where the chronic nature of illness is terminal. And many times, it is exacerbated by a hospitalization. However, the misconception is that Hospice Services means you are near death. This is not true. Qualifying simply means that you are not likely to reverse the trajectory of an illness or condition. Some common Hospice Diagnoses include Heart Failure, Alzheimer’s Dementia, COPD, aggressive and/or late-stage Cancer, and Renal Failure. Technically, to qualify, a Doctor has to state your life expectancy is six months or less. But many hospice patients can be cared for at this higher level of care for even years. This benefit is the only benefit that is still covered by Medicare at 100%. There are no copays or coinsurance for these services. Hospice is a higher level of care than Home Health but still is not round the clock care in most cases. Hospice visits will be made by a Nurse, Nurse Aide, Social Worker, Chaplain and Volunteers. This service is done mostly in your own home, but there are some free-standing Hospice Facilities. It is a beautiful service and provides a holistic approach to the quality of life. It is a way to manage the inevitable end of life with dignity.
With 20 years of experience in Post Acute Care, CDI brings a diverse range of knowledge to support you and your loved ones. From Post Acute Care, Insurance, Managed Care and VA Resources, CDI can help you through this entire maze. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.
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"The good life is one inspired by love and guided by knowledge." - Bertrand Russell
