Medicare Access Project for People Living With ALS
Medicare Overview – With an Emphasis on the Home Health Care Benefit
Frequently Asked Questions and Answers
- Can they be using a walker instead of crutches in homebound example?
Yes, the homebound definition generally is intended to provide home health care for people who lack an ordinary ability to leave home. The definition includes a provision that an individual requires assistance of an individual or supportive device and it requires “considerable and taxing effort” to leave home.
- Are home health aides able to care for someone with a tracheostomy?
Yes, but typically not care that requires “skilled” care. Home health aides provide primarily personal, hands-on care. A home health aide may assist with tasks such as dressing, bathing, assisting someone to transfer or reposition, laundering of personal items or bed linens, and similar tasks.
- When a nurse comes, we were told that they have to have a list of tasks that will keep them there for that amount of time, is that true?
Once skilled nursing care is determined as reasonable and necessary, the amount of time that a nurse is required to be in the home should be delineated in the plan of care and should be adequate time to cover the skilled tasks that the nurse is to perform (observation, assessment, care plan management, patient education services, other specific services.
- Can you give us an example of needs which would require 28-35 hrs/wk of care?
The 28-35 hours per week would include a combination of what Medicare defines as both skilled nursing care and home health aide services (also called personal care services). Generally, skilled nursing care includes overall management and evaluation of care plan, observation and assessment of the patient’s changing condition, patient education services, and other skilled nursing tasks. Generally, personal care services include assistance in dressing, eating (not tube feeding, which is considered a skilled task), toileting, bathing, positioning, exercising supervision, maintenance care of devices, administering medications and ointments, changing dressings laundering personal items and bedding, and fixing light meals. 42 C.F.R. § 409.33.
- Does Medicare pay for home care?
Medicare does pay for home health care and there is no limit on how many 60 day “episodes” Medicare may cover. Please watch the ALS-MAP Webinar for coverage details.
- Can I use home health care hours for nights?
Medicare coverage does not distinguish between “day” or “night” care. If an individual meets Medicare coverage criteria for the home health care services, the timing of those services should be discussed in the plan of care.
- Is therapeutic massage covered?
Medicare does not cover the services of a massage therapist, but similar services may be a covered component of services that are provided by a physical therapist. See 42 C.F.R. § 409.33 (c) 1-8.
- Where does respiratory therapy fit into this?
Skilled service? If a respiratory therapist is used to furnish overall training or consultative advice to a HHA’s staff and incidentally provides respiratory therapy services to beneficiaries in their homes, the costs of the respiratory therapist’s services are allowable as administrative costs. Visits by a respiratory therapist to a beneficiary’s home are not separately billable. However, respiratory therapy services that are furnished as part of a plan of care by a skilled nurse or physical therapist and that constitutes skilled care may be separately billed as skilled visits. 42 C.F.R. § 409.46 (c).
- Does Medicare pay for a home generator if electricity is needed for respiratory care in case of electrical outage?
Medicare will not pay for a home generator. The definition of durable medical equipment (DME) for Medicare coverage includes equipment which is generally not useful to a person in the absence of an illness or injury. MBPM, Chapter 15 § 110.1. Since a home generator may be useful to a person in the absence of an illness or injury, it is not coverable by Medicare.
- Can home care patient be discharged due to a caregiver being educated?
Educating a caregiver is a Medicare covered service. Teaching and training activities that require skilled nursing personnel to teach a patient, the patient’s family or caregivers how to manage the patient’s treatment regimen would constitute skilled nursing services. MBPM Chapter 7, § 126.96.36.199.
- Can someone say a caregiver is too old to be trained?
No one can ever say a caregiver is too old to be trained. Age is not relevant. Where it becomes apparent, after a reasonable period of time, that the patient, family, or caregiver will not agree to be trained, or is not able to be trained, then further teaching and training would cease to be considered to be reasonable and necessary by Medicare. MBPM Chapter 7, § 188.8.131.52.
- Who’s supposed to cover the incontinence briefs if patient is receiving home health services?
Medicare offers limited coverage of incontinence supplies for home health. Incontinence briefs are covered as a routine medical supply in the normal course of a visit. That means Medicare will cover incontinence supplies that home health staff use during their visits, but the home health agency (HHA) does not have to leave supplies in the home for use by the patient or family caregivers between home care visits. MBPM, Chapter 7 § 184.108.40.206.D.
- When an ALS patient is admitted into the hospital for pneumonia and is there for 3-5 days in the middle of a 60 day episode of home health services does the home health agency services stop and a new episode has to start when they are discharged?
Home health coverage would be stopped during the hospitalization and restarted at discharge, assuming the 60 day home health episode had not ended. In the event a person is admitted to an inpatient facility and the inpatient stay overlaps into what would have been a subsequent episode and there is no new certification assessment of the patient, then the new certification begins with the new start of care date after the inpatient discharge. For these and other hospitalization examples, see MBPM, Chapter 7 § 10.10.H.
- Is the RN limited to 21 consecutive days or 21 visits?
No, there is no durational limit on coverage for home health care. Assuming skilled nursing care is considered reasonable and necessary, it must be performed on a part-time or intermittent basis. 42 C.F.R. § 409.44(b). Part-time or intermittent means skilled nursing and home health aide services (furnished any number of days per week) as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week). MBPM, Chapter 7 §§ 40, 50.7.
- What are the qualifications of a skilled professional? Is a CNA considered skilled?
For Medicare coverage purposes, care provided by a CNA is not considered to be skilled nursing care. Skilled nursing care consists of those services that must, under State law, be performed by a registered nurse, or practical (vocational) nurse. 42 C.F.R. § 409.44(b)(1). To be covered as skilled nursing services, the services must require the skills of a registered nurse or a licensed practical (vocational) nurse under the supervision of a registered nurse. MBPM, Chapter 7, §40.1. If all other eligibility and coverage requirements under the home health benefit are met, skilled nursing services are covered when an individualized assessment of the patient’s clinical condition demonstrate that the specialized judgment, knowledge, and skills of a registered nurse or, when provided by regulation, a licensed practical (vocational) nurse are necessary. MBPM Chapter 7, § 40.1.1.
- Both parts A and B provide coverage for Home Health care?
Yes, Medicare Part A or Medicare Part B covers home health care. There is no difference in coverage type between Part A or Part B. To the extent that all coverage requirements are met, payment may be made on behalf of eligible beneficiaries under Part A for an unlimited number of covered home health visits. All Medicare home health services are covered under hospital insurance unless there is no Part A entitlement. 42 C.F.R. § 409.48(a). Medicare home health services are covered under Part B only when the beneficiary is not entitled to coverage under Part A. 42 C.F.R. § 209.48(b).
- Did not see RT (resp. therapy) as a triggering event but this would be very common with ALS patients. Can it be a trigger?
Respiratory therapy is not a triggering event for Medicare Home Health care coverage. If a respiratory therapist is used to furnish overall training for consultative advice to a HHA’s staff and incidentally provides respiratory therapy services to beneficiaries in their homes, the costs of the respiratory therapist’s services are allowable as administrative costs. Visits by a respiratory therapist to a beneficiary’s home are not separately billable. However, respiratory therapy services that are furnished as a part of a plan of care by a skilled nurse or physical therapist and that constitute skilled care may be separately billed as skilled visits. 42 C.F.R. § 409.46 (c).
- Is there a limit to the number of hours w day/week/month to the homecare benefit?
The unit of payment under the Home Health Prospective Payment System (HH PPS) is a national 60-day episode rate, with applicable adjustments. MBPM Chapter 7, § 10. HH PPS permits continuous episode re-certifications for patients who continue to be eligible for the home health benefit. Medicare does not limit the number of continuous episode re-certifications for beneficiaries who continue to be eligible for the home health benefit. MBPM, Chapter 7, § 10.3. For any home health services to be covered by Medicare, the patient must meet the qualifying criteria, including having a need for skilled nursing care on a part-time or intermittent basis, and/or physical therapy, and/or speech-language pathology services, and/or a continuing need for occupational therapy. The term “part-time or intermittent” for purposes of coverage means skilled nursing AND home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week) MBPM Chapter 7, § 40, § 50.7.
- Medicare pays per visit not per hour? How does this work?
Medicare does not pay by hour or by visit. Medicare pays on a national 60-day episode rate with applicable adjustments. The law requires the 60-day episode to include all covered home health services, including medical supplies, paid on a reasonable cost basis. That means the 60-day episode rate includes costs for the six home health disciplines (skilled nursing services, home health aide services, physical therapy, speech-language pathology services, occupational therapy services and medical social services), the costs for routine and non-routine medical supplies, and therapies that could have been unbundled to Part B coverage prior to HH PPS. Adjustments to the 60-day episode rates are case-mix adjustments (clinical severity, functional severity, and service utilization) and labor adjustments by location. MBPM Chapter 7, § 10, 10.1(A) and (B).
- Does HHC supply enemas for a PALS bowel program?
Medicare provides the following example, the condition of a patient…may be such that he or she can be given an enema safely and effectively only by a nurse. If the enema were necessary…, then the visit would be covered as a skilled nursing visit. The documentation must support the skilled need for the enema, and the plan for future visits based on this information. MBPM, Chapter 7, § 40.1.1 Example 2.
- Is an HHC company responsible for all medical supplies & care needed?
For example – condom catheters? All costs for routine and non-routine medical supplies are included in the home health care 60-day episode rate. MBPM Chapter 7, §§ 10.1.A., 10.11.B.
- Is there a way for Medicare to reimburse a nurse/assistant who is NOT part of a home health care agency?
Yes, under arrangement with the home health agency (HHA). For individuals under a home health plan of care, payment for all services and supplies, with the exception of osteoporosis drugs and durable medical equipment (DME), is included in the HH PPS base payment rates. HHAs must provide the covered home health services (except DME) either directly or under arrangement, and must bill for such covered home health services. Payment must be made to the HHA. MBPM Chapter 7, § 10.11. A HHA is responsible for payment in the situation in which services are provided to a patient by another entity, under arrangement with the HHA, during an episode in which the patient is under the HHA’s home health plan of care. MBPM Chapter 7, § 10.11.E.
- What does homebound mean?
The criteria to qualify for home health care includes being confined to the home, under the care of a physician, in need of skilled services, and under a plan of care. 42. C.F.R. § 409.42. The criteria to be confined to the home, or “homebound”, is typically analyzed in two steps. Step one states that the patient must have one of two circumstances: 1. Because of illness or injury, the patient needs the aid of a supportive device, such as crutches, cane, wheelchair or walker, or needs the use of special transportation, or needs the assistance of another person in order to leave their place of residence, or 2. The patient has a condition such that leaving his or her home is medically contraindicated (such as being medically fragile or medically compromised). Step 2 states that there must exist a normal inability to leave the home AND leaving home must require a considerable and taxing effort. If a patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. MBPM, Chapter 7 § 30.1.1.
- Am I understanding that an ALS patient cannot receive home care assistance (for personal hygiene help) if they are in a wheelchair and leaving the home trying to lead a normal social existence?
The answer to this question requires more analysis of the individual’s situation, and likely will turn on the person’s “normal inability to leave the home”. Occasional absences from the home for non-medical purposes, e.g. an occasional trip to the barber, a walk around the block or a drive, attendance at weekly faith services, a family reunion, funeral, graduation, or other infrequent or unique events would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home. MBPM, Chapter 7 § 30.1.1
- In regard to home health coverage, could it be discontinued if PALS takes a vacation with equipment and taxing effort but not a specialized vacation/destination such as the cruise you spoke of your in your example?
This would likely be allowed. The absence would be considered “an infrequent basis”. It would be important to document why there is a considerable and taxing effort, the supportive devices and the assistance of others used, the provisions made to ensure there is a plan for what would happen in the event of a medical emergency. It would also be helpful to indicate the level of “participation” the patient had in the vacation activities (or lack of participation), and how much the patient rested during the trip.
- If an ALS patient qualifies as homebound and the doctor writes a care plan to have a RN visit once a month to check the status of the patient and includes a home health aide 4 x per week at 3 hours per visit does any other service need to be added?
I guess the true question is can a HHA be the main service that the pt. is receiving? Yes, again assuming the person is confined to the home, under the care of a physician, in need of skilled services, and under a plan of care, in this particular scenario, Medicare should approve coverage. Orders for care may indicate a specific range in the frequency of visits to ensure the most appropriate level of services is provided during the 60-day episode to home health patients. See MBPM, Chapter 7 § 30.2.2. The skilled nursing (at one visit a month), and the home health aide (at a total of 12 hours a week) is “intermittent” as it is furnished less than 8 hours each day and 28 or fewer hours each week. See MBPM, Chapter 7 §§ 40, 50.7.
- Does Medicare cover Physical Therapy for a patient that is not homebound?
Yes. But not under the home health care benefit. Physical therapy is a covered Part B service. Evaluations and treatment for an injury or disease that changes a person’s ability to function are usually covered. A doctor or other health care provider must certify the need for physical therapy. There is usually a limit of $1,960 per year, but there may be some exceptions to these limits. Physical therapy covered as a Part B benefit is subject to the Part B deductible and 20% co-insurance.
- Does it matter how many times I leave the home per week or where I go – outside of Dr, ADC? Example – Grocery, Post Office, Library, Going out to lunch.
Medicare has no “rules of thumb” about how many times a week someone leaves their home or where they go. All of an individual’s circumstances will be considered. Leaving the home for health care treatment is the most “appreciated” reason for leaving the home (Medicare also notes attendance at adult day centers to receive medical care is acceptable). Going to the grocery store, post office and library infrequently or for periods of short duration are usually acceptable. If someone is leaving their house every day of the week for non-medical reasons, Medicare may (or may not) say that demonstrates a “normal ability to leave home” even if it does require a considerable and taxing effort and assistance. There are no cut-and-dried answers, but duration and distance should be taken into consideration.
- You mentioned that a home health aide can be paid for by Medicare through a supervising HHA under an arrangement. I have an aide I am paying for privately now. I am getting skilled nursing, bath aide, PT and ST therapy from an HHA provider now. I have been trying to get my aide paid for by Medicare through the HHA and they have been non-cooperative in either hiring her directly and also saying home health aide coverage is only for bath aide.
It sounds like you are saying she can be paid through Medicare WITHOUT having to go to work for them….is this what you are saying? Can you please explain this in more detail? Once a patient elects to receive home health coverage, payment for all services and supplies is included in the payment rate for the episode. MBPM Chapter 7, § 10.11. A patient may ask the HHA to make “arrangements”, such as a contract service, with someone who is not their employee. But they are not required to contract with the individual. The HHA’s consolidated billing role supersedes all other billing situations the beneficiary may wish to establish for home health services covered under the scope of the Medicare home health benefit during the certified episode. MBPM Chapter 7, § 10.11.D. If the HHA is saying that home health aide coverage is only to aide in bathing, this is incorrect. A home health aide generally is covered for personal care services which may include assistance in dressing, eating (not tube feeding, which is considered a skilled task), toileting, bathing, positioning, exercising supervision, maintenance care of devices, administering medications and ointments, changing dressings laundering personal items and bedding, and fixing light meals. 42 C.F.R. § 409.33.
- I contacted my Neurologist about a skilled nurse for my bedsore, a PT for range of motion, and a home health aide to help me in toileting. The PT is telling me that she can see me for a month or two and then it ends. Medicare demands that the PT has a goal for progress not just maintenance. Medicare wants her to train someone to continue the PT. My caregiver is my ex. She is a breast cancer survivor and had a mastectomy. She has trouble moving me. The aides will only come when they have an opening, not when I need someone to help me go to the bathroom. What can I do?
Each of the issues (skilled care to assess and treat bedsore, PT for range of motion, and home health aide for toileting) are all included for Medicare coverage. The PT is incorrect in stating you have any durational limit for PT coverage. As long as there is a need for PT services, including range of motion, to maintain the current condition or to prevent or slow further deterioration, no improvement or “progress” is required. Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patient’s potential for improvement from the nursing care or therapy, but rather on the patient’s need for skilled care. The plan of care will require that there be “goals” but “goals” may be defined as maintaining the patient’s current condition or preventing or slowing further deterioration of the patient’s condition. MBPM Chapter 7, § 20.1.2. As for the toileting, your Medicare coverage will extend for home health aides as long as they are furnished (along with skilled nursing, combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week). MBPM Chapter 7, § 40, 50.7. Assuming it is 35 hours, the HHA bills Medicare for the skilled nursing and home health aide services, which were provided by the 35th hour of service each week, and bills the beneficiary (or another payer) for the remainder of the care (up to 24 hours per day, 7 days per week for the home health aide). MBPM Chapter 7, § 50.7.1.
- Can the home health care agency limit coverage when they are wanting to go to a maintenance program for the ALS patient and reduce the PT, OT, and Home Health Aide services when the primary care physician has written a prescription for the services to continue as they have always been so that the patient maintains the most function as ALS changes?
In most circumstances, no. Medicare recognizes that determinations of whether home health services are reasonable and necessary must be based on an assessment of each beneficiary’s individual care needs. MBPM Chapter 7, § 20.3. The plan of care must include a course of treatment for therapy services with measureable treatment goals, expected duration of therapy services, and description of a course of treatment which is consistent with the qualified therapist’s assessment of the patient’s function. MBPM Chapter 7, § 30.2.1. There is no difference in coverage afforded to a patient based on maintenance versus improvement. It is based only on objective clinical evidence regarding the patient’s individual need for care. Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patient’s potential for improvement from the nursing care or therapy, but rather on the patient’s need for skilled care. The plan of care will require that there be “goals” but “goals” may be defined as maintaining the patient’s current condition or preventing or slowing further deterioration of the patient’s condition. MBPM Chapter 7, § 20.1.2.
- I am getting OT, an RN once a week, an LVN once a week and an aide 3 days a week. Should I be able to have an aide 5 days a week? I have lost use of left hand, am now losing right.
Medicare coverage for the RN, LVN and aide (combined, as long as they are furnished), are for less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week). MBPM Chapter 7, § 40, 50.7. Assuming it is 35 hours, the HHA bills Medicare for the skilled nursing and home health aide services, which were provided by the 35th hour of service each week, and bills the beneficiary (or another payer) for the remainder of the care (up to 24 hours per day, 7 days per week for the home health aide). MBPM Chapter 7, § 50.7.1.
- I was told by a home health company that since I was not showing improvement, they were not set up to just to provide maintenance. They said they would lose their Medicare license. Also said it was to be for only a short time i.e. 30 days. PT told me to do it myself. Who can I talk to get help?
Perhaps either through your local ALS Association Chapter or family or friends, you should contact other Medicare certified HHA to see if any of the other HHAs understands that coverage for “maintenance” of your condition is as equally coverable by Medicare as it is for someone who might be expected to improve.
- What happens if a patient initially requires skilled services and qualifies for a home care aide but then the skilled services are no longer needed but a home health aide is needed?
To receive Medicare coverage for home health services, some type of skilled care is always required. The skilled care may be nursing care (must be reasonable and necessary, intermittent, and not solely needed for venipuncture for the purposes of obtaining blood sample). Or the skilled care may be physical therapy, speech-language pathology services, or occupational therapy (a continuing need). MBPM Chapter 7, § 30.4. Home health aide alone is not a covered service.
- What if HH (PT) requires you to sign an ABN because "they" think Medicare will not cover it? And if the claim is denied will I have to pay HH – during claim appeal?
Refer to the Self-Help Packet for Home Health Care Appeals. Beneficiaries in traditional Medicare have a legal right to an Expedited Appeal when home health providers plan to discharge them or discontinue Medicare-covered skilled care. (Note: An Expedited Appeal is not triggered when the provider lowers the frequency of skilled care.) To try to prevent the discontinuation of Medicare Covered Care, call the telephone number for the Quality Improvement Organization listed on your notice no later than noon of the calendar day following the receipt of the notice. Remember that Medicare only pays for care that has been provided, not care that “should” have been provided. In the event that the Expedited Appeal fails and you continue to receive care, you should ask the HHA to put a bill into the Medicare system to see if Medicare will pay for the services you received.
- My wife is on a ventilator and cannot be left alone. What kind of care is covered?
Ventilator Care is considered a skilled service. Teaching of any service otherwise defined as skilled is also a skilled service. Administration of medical gases and fall prevention and home safety issues taught to a patient or the patient’s family/caregiver are coverable home health services. Medicare does not pay for 24-hour home care. If skilled nursing needs are full-time and not intermittent, an individual may qualify for Medicare home care coverage based on the need for other covered skilled care (physical therapy, speech-language pathology, or continuous occupational therapy). Once a person qualifies for any skilled, home health coverage may also include the personal care services of a home health aide for less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week). MBPM Chapter 7, § 40, 50.7.
- If you are on a ventilator and paralyzed, don’t you always need a skilled nurse?
Medicare states that a service, by its nature, requires the skills of a nurse to be provided safely and effectively, continues to be a skilled service even if it is taught to the patient and the patient’s family or other caregivers. MBPM Chapter 7, § 40.1.1. Medicare considers all the following to be skilled services medically necessary as associated with ventilator care: 1. Ventilator management and evaluation and assessment for changes in the patient’s condition, particularly in situations where the patient’s respiratory status is unstable and may change suddenly and unpredictably, and require medical treatment; 2. Ventilator management includes changes in settings, ventilator maintenance, and cleaning of internal ventilator components; 3. Initiation of and changes in regimens involving administration of medical gases; 4. Insertion and replacement of tracheal cannula; and 5. Active weaning of ventilator dependent individuals.
- Will the benefit cover someone who is in a clinical trial and requires injections because of the trial?
Please refer to the brochure “Medicare and Clinical Research Studies” to understand Medicare coverage for an individual who chooses to participate in a clinical trial. https://www.medicare.gov/Publications/Search/results.asp?PubID=02226&PubLanguage=1&Type=PubID