Daily Local News (West Chester, PA)
Is it becoming harder to get Medicare-covered home health care?
Medicare beneficiaries have a benefit, often underused, that will provide intermittent skilled care at home if the beneficiary meets certain criteria, and has a physician order for care. This care is extremely important, both temporarily to provide physical therapy or occupational therapy at home, oversight by a skilled nurse, or assistance of an aide, or to provide continued skilled care and bathing assistance for those with serious chronic illnesses. However, some beneficiaries who are utilizing needed skilled care at home under their Medicare benefit are being told that Medicare has changed the rules and they no longer qualify for coverage. An article from Kaiser Health News on February 4 explains what has changed and how to fight for benefits. (https://khn.org/news/what-todo-if-your-home-health-careagency-ditches-you/).
The article begins with a story of a 71year old husband, and caregiver for his wife with advanced MS. His wife did not receive a lot of care, an aide two days a week to help bathe her, and a nurse one time every two weeks to evaluate her suprapubic catheter and to change it as scheduled. His wife’s urologist had ordered the care at home as it was safer to change the catheter in the home setting since his wife used a lift system to transfer which is not available in the doctor’s office. Abruptly, the care was discontinued since “Medicare had changed its payment system for home health.”
The only change is that Medicare now pays agencies under a new system known as the “Patient Driven Groupings Model” or PDGM. It only applies to older adults with Original Medicare. Payments are based on a number of factors, including the patient’s underlying diagnosis. However, the benefits have not changed. The Center for Medicare Advocacy (www. medicareadvocacy.org) has information on their website regarding this.
The author of the Kaiser Health News has some tips if you find yourself at odds with a Medicare certified home care agency. First is to find out as much information from them as possible, including what criteria that you no longer meet. If the agency says that they no longer cover a particular service, that should raise red flags, as Medicare has not changed its benefits or clinical criteria. Next, enlist your doctor’s help. The doctor must have ordered the service and re-certify such orders at regular intervals. He or she may be unaware that you are not receiving services that you feel that you continue to need and that the doctor believes are being provided.
Other tips include contacting an ombudsman. Home health agencies do not have dedicated long-term care ombudsmen to represent patients’ interests. But there is a general Medicare ombudsman to which you can submit an inquiry or a complaint. Call 1-800-Medicare and ask for a representative to look into such a dispute. You can also contact an advocate, such as the Center for Medicare Advocacy mentioned earlier, or the Medicare Rights Center (800333-4114).
Other ideas are to shop around. There are likely multiple options for Medicare home care agencies in your area. Finally, you or your loved one must be given proper notice when services are discontinued. The Notice has information to request an expedited appeal.
Do not take discontinuance of your Medicare benefits lying down. Make sure that your rights are not being violated.
The legal advice in this column is general in nature, Consult your attorney for advice to fit your particular situation.