Pqhh Survey Finds Proposed Payment Rates Will Harm Patient Care
Washington, D.C. The Partnership for Quality Home Healthcare recently released the results of an independent study that found the Medicare home health sector faces increased demand, a dwindling talent pool, and financial challenges due to inflation and pressures from the pandemic. The results show that the Centers for Medicare & Medicaid Services Home Health Prospective Payment System proposed payment adjustments for Calendar Year 2023 will result in financial harm to providers and undercut patient care and quality at a time when in-home care is an essential option for patients. Further, home health is increasingly preferred by patients, families and caregivers, and the cost of care is increasing faster than Medicares payments due to staffing shortages and surging costs for resources. The studyconducted independently by Dobson | DaVanzo & Associates to investigate changes in the home health labor costs of member agenciesfound that home health agencies will likely need to increase wages for clinical staff more quickly than in the past in order to be competitive at a time when agencies find it difficult to maintain operations due to an insufficient supply of clinicians and high home health staff turnover from employer competition. Other key findings of the study include:
Medicare Advantage Plans Telling Rehab Patients To Go Home Early
But instead of being relieved, Christopherson and her daughter were worried because her medical team said she wasnt well enough to leave.
This seems unethical, said daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, run by UnitedHealthcare, ended coverage for her mothers nursing home care.
The facility gave Christopherson a choice: pay several thousand dollars to stay, appeal the companys decision or go home.
Health care providers, nursing home representatives and advocates for residents say Medicare Advantage plans are increasingly ending members coverage for nursing home and rehabilitation services before patients are healthy enough to go home.
Half of the nearly 65 million people with Medicare are enrolled in the private health plans called Medicare Advantage, an alternative to the traditional government program. The plans must cover at a minimum the same benefits as tra
ditional Medicare, including up to 100 days of skilled nursing home care every year.
But the private plans have leeway when deciding how much nursing home care a patient needs.
In traditional Medicare, the medical professionals at the facility decide when someone is safe to go home, said Eric Krupa, an attorney at the Center for Medicare Advocacy, a nonprofit law group that advises beneficiaries. In Medicare Advantage, the plan decides.
That can lead to quick denials and added stress.
Its not just one plan, he said. Its pretty much all of them.
Older
How Much Does Medicaid Pay Towards A Nursing Home
Some Medicaid services are covered 100 percent, but others are not. Because individual states manage their own Medicaid programs, the extent of coverage depends on your facility’s location. For example, different states might cover routine dental services or have higher cost allowances. The federal government does require Medicaid-certified nursing homes to provide the same minimum services.
Medicaid Pays For*
- Specialized rehabilitation
*Level of service varies by state
Medicaid Does not Pay For
- Personal comfort items
- Cosmetics or extra grooming products
- Social activities beyond the facility’s activity program
- Special care outside Medicaid-contracted coverage
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How To Find Nursing Homes That Accept Medicaid Near Me
Below are a few resources and tips for finding a Medicaid-approved nursing home in your area.
- Use Medicaid’s search tool. This online tool lets you look for pre-vetted facilities by Zip Code.
- Ask your doctors if they service any Medicaid-certified nursing homes.
- Ask friends, family, and colleagues you trust.
- Contact an Aging and Disability Resource Center .
- If you’re in the hospital, talk to a social worker about post-discharge care planning.
- They may be affiliated with or know reputable, certified Medicaid nursing homes.
Don’t Leave Your Hard-Earned Benefits Behind. Call to get connected with a licensed agent.
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A: Have A Professional Informal Eligibility Assessment
Once you have made the decision that the applicant will be financially eligible, it is recommended you confirm this assessment with a professional. Submitting your application correctly the first time is a lot of work, but its still much easier than having to appeal a denial. Any mistakes make a delay or denial of benefits more likely, even if the applicant is eligible.
One way to get help is a benefits counselor at your local Area Agency on Aging. AAA offices are meant to help with exactly this sort of issue for older adults, and they will be experts on your specific state requirements. Theyre also free. The downside of getting help from AAA, however, is that theyre busy and may not be able to assist as soon as youd like. To find your local AAA office, .
Another option to get help with your Medicaid application is a Certified Medicaid Planner. Unlike the AAA benefits counselor, CMPs are paid services. CMPs will, however, offer an initial consultation for free. https://cmpboard.org/ For much more on Medicaid planning, see below.
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Subheadinghere You’ll Find Our Nursing Home Resources Including Covid
In February, the Biden Administration announced a comprehensive set of reforms to improve the safety and quality of nursing home care. One key initiative within the Presidents strategy is to establish a new minimum staffing requirement. CMS launched a multi-faceted approach aimed at determining the minimum level and type of staffing needed to enable safe and quality care in nursing homes, which includes conducting a mixed methods study with qualitative and quantitative elements to inform the minimum staffing proposal. CMS has held listening sessions with the general public to provide information on the study and solicit additional stakeholder input on minimum staffing requirements.
How And When Medicaid Can Pay For A Nursing Home
Thomas J Catalano is a CFP and Registered Investment Adviser with the state of South Carolina, where he launched his own financial advisory firm in 2018. Thomas’ experience gives him expertise in a variety of areas including investments, retirement, insurance, and financial planning.
Medicaid was created in 1965 as a social healthcare program to help people with low incomes receive medical attention. Many seniors rely on Medicaid to pay for long-term nursing home care.
Most people pay out of their own pockets for long-term care until they become eligible for Medicaid. Though Medicare is an entitlement program, Medicaid is a form of welfareor at least thats how it began. So to be eligible, you must become impoverished under the programs guidelines, says Laura M. Krohn, a Rhode Island-based elder law attorney.
Let’s look at how the economics work, and how Medicaid can be used to pay for a nursing home.
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Choosing A Nursing Home
Lifestyle. Think about aspects of your care that are important to you. Can you maintain a lifestyle similar to what you would at home? If you follow a religion, consider whether you can attend or watch worship services.â
Location. You may want to live near family so they can visit easily. If you live in a town with no relatives, consider moving to an area closer to someone in your family.â
Ask for recommendations. Talk to your friends and family about what they think. Chances are, they know other people in nursing homes who can share pros and cons.
Before visiting, call and ask questions over the phone. Make a list of answers for each facility to compare notes easily. Write down any remaining questions you have so you can address them in person or when you call again.â
Visit in person. Make sure you tour facilities when possible. You may not be able to go in person because of visitor restrictions. If this happens, ask for photos and videos of the rooms. Request detailed information about what living and care are like at the nursing home.â
If you can visit in person, make several trips. Visit at least once without announcing. Doing this gives you a better idea of what the facility is like on an average day.â
Show Sources
American Council on Aging: âMedicaid Coverage of Nursing Home Care | When, Where and How Much They Pay.â
Medicaid: âNursing Facilities.â
Gather Eligibility Criteria For Nursing Home Medicaid
The information youll need to complete the application for yourself or a loved one to receive Nursing Home Medicaid will have specific details and nuances that vary depending on your state. You can read a full article on Nursing Home Eligibility at this link, or use a search tool that provides specific eligibility criteria for where you live and your marital status.
Medicaid is not Medicare
Very generally, however, we can say that being accepted to receive Nursing Home Medicaid depends on meeting two levels of criteria:
1) Functional needs: Broadly, functional or physical needs means a person requires help with activities of daily living , which are the independent actions we take every day to keep ourselves healthy, like bathing or eating. An assessment by a medical professional determines functional needs.
2) Financial needs: Medicaid is for people who are low-income with limited assets. What this means in your specific state might be different from others, but usually someone who has income under $2,523 per month and less than $2,000 in countable assets would qualify financially.
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Does Medicare Cover Nursing Homes
Medicare covers some nursing home costs, but only for short, approved visits. Medicare Part A covers some specific, short-term services within a skilled nursing facility if deemed medically necessary. For example, it covers skilled treatment for an injury or illness in a nursing home.
Original Medicare only pays for nursing home care up to 100 days maximum . Some Medicare Advantage plans also offer partial coverage, but only if the nursing home contracts with that plan.
Medicare does not cover long-term nursing home care, also known as custodial care. This includes the routine, sometimes unskilled services like help with bathing, dressing, or bathroom use. Medicare does cover a limited number of services within nursing homes for patients who meet specific criteria.
What Is Covered by Medicare
- Medical and nursing care up to 100 days in a skilled facility
- Prescription medication covered under Medicare Part A
What’s not Covered by Medicare
- Long-term, custodial care
- Enrolled in Medicare Part A .
- Available days in your benefit period.
- Qualifying hospital stay: three or more days hospitalized as an inpatient .
- Enter a Medicare-approved facility within 30 days of qualifying hospital stay.
- A doctor determines you need daily skilled care.
- The skilled nursing facility is Medicare-approved.
- Hospital-related medical condition treated during a qualifying stay.
Medicaid For Pennsylvanians Needing Home Health Care
Home health care can include skilled nursing or therapy services, home health aide services like medication management or bathing assistance, and personal care aide services like meal preparation or cleaning. Pennsylvania has several programs that offer payment for home care services.
First, if you receive Medicaid, the program will pay for some limited home care services. The services must be prescribed by your doctor as part of a plan of care for a particular problem, and the services must be directed at curing or rehabilitating you.
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Who Is Eligible For A Health Home
Health Homes are for people with Medicaid who:
- Have two or more chronic conditions
- Have one chronic condition and are at risk for a second
- Have one serious and persistent mental health condition
Chronic conditions listed in the statute include mental health, substance abuse, asthma, diabetes, heart disease, and being overweight. Additional chronic conditions, such as HIV/AIDS, may be considered by CMS for approval.
- States can target health home services geographically
- States cannot exclude people with both Medicaid and Medicare from health home services
Types Of Waiver Programs
If you are 60 or older, you may qualify for Pennsylvania’s Aging Waiver. The program offers home-delivered meals, home health services, transportation, personal assistance, emergency response systems, and accessibility modifications to your home.
If you are younger than 60 and have a physical disability, you may qualify for Pennsylvania’s Attendant Care Waiver. Depending on your income, you may be required to contribute to the cost of your services. If you qualify, the Attendant Care Waiver can provide you with personal support, home health services, emergency response services, and specialized equipment and supplies to help you live independently. Pennsylvania has similar waiver programs for other specific populations, like people with developmental disabilities, people with AIDS, and people with traumatic brain injuries.
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What Types Of Long
Long-term care includes care provided at:
- a nursing facility
- an assisted living facility, and
If you require long-term care and both your income and your assets fall below certain levels established by your state, then federal law requires your state’s Medicaid program to pay for nursing home care. In the past, this was the only type of long-term care covered by Medicaid. But in more recent years, states have also begun to cover at-home care and assisted living care through new pathways. Most commonly, coverage for HCBS is provided through a state “waiver” programso called because the program waives certain federal requirements that restrict states, and allows states to operate more freely.
All states now offer some level of benefits for use in home settings, but the breadth of coverage varies widely. For example, state waiver programs for home care do cover nursing care and home health aide services in your home, as well as physical, occupational, and speech therapy, but only some states will cover personal caremeaning assistance with bathing, dressing, eating, and using the bathroom.
Does Medicaid Cover Nursing Homes
Medicaid covers nursing home costs if you qualify. Medicaid is the largest fund-source for nursing home care. For eligible seniors, Medicaid covers long-term nursing home care in Medicaid-certified facilities4 when medically necessary. You’ll have to be under a certain income level and meet other state-specific requirements to qualify.5
All 50 states offer Medicaid, but nursing home services, cost coverage, and eligibility requirements vary widely by state. For example, each state sets its own income limit to determine if you are eligible for Medicaid. Not all nursing homes accept Medicaid, so check with each facility.
Unlike Medicare, Medicaid does not impose an official time limit on nursing home stays as long as they’re in a licensed and certified Medicaid nursing facility.
What Is Covered by Medicaid
- Long-term care covers nursing home stays for qualifying patients needing ongoing care for a chronic mental or physical condition.
- Skilled nursing and related medical care.
- Rehabilitation from illness, injury, or disability.
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Asset Income Levels Differ In Each State
Medicaid eligibility and application procedures vary from state to state.
The federal-state program was established to pay for health care for those who are unable to afford or obtain health insurance, so all states have asset and income limits that govern who can receive coverage, but it’s not one ceiling nationwide.
“Medicaid is often of importance to middle-income Americans because Medicare does not cover the costs of long-term care for illnesses such as Alzheimer’s disease or paralysis caused by a stroke. Most people who need such care for extended periods will eventually deplete their assets and become unable to pay the costs of their care, according to a brochure available online from the National Academy of Elder Law Attorneys .
B: Applicant Is Financially Ineligible For Nursing Home Medicaid
If you have gathered information and realized that the person applying for Nursing Home Medicaid is not financially eligible due to being over the monthly income or asset limit, there are still avenues for people over the limits to receive Nursing Home Medicaid benefits, as Medicaid offers various ways to become eligible for applicants who may seem at first to be above their limits.
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Misconception : Is It True That If I Apply For Medicaid The Federal Government Will Pay For Everything
Not exactly. Medicaid is funded jointly by the state and federal government however, Medicaid is generally run by the state you live in, not the Federal government.
For those who meet the income and asset guidelines to apply for Medicaidand are also 65 or older and qualify for Medicare dual coverage is established. In instances when Medicare typically provides coverage, Medicare covers costs for services first.
Medicaid is in fact responsible for covering nursing home care past the point of Medicare coverage. Elder law attorney and Partner Joshua Beisker of Underberg & Kessler LLP explains that long-term care costs make up about a quarter of all health care expenses picked up by Medicaid, with hospital care, physician services, and prescription drug costs accounting for the rest. Federal rules require state Medicaid programs to cover certain mandatory services, such as hospital and physician care, laboratory and x-ray services, home health services, and nursing home care for adults.
Beisker adds that Medicaid covers more than 60 percent of all nursing home residents and roughly 50 percent of costs for long-term care services and supports. He also explains that Medicaid does not provide health care directly. The large majority of Medicaid beneficiaries are covered through private managed care plans. For others, state Medicaid programs pay hospitals, doctors, nursing homes, and other health care providers for covered services that they deliver to eligible patients.
B: Investigate Alternate Pathways To Eligibility For Nursing Home Medicaid
Medically Needy MedicaidMedically Needy Medicaid is available in 36 states, and Washington D.C., and is for getting Medicaid benefits to people who spend a significant amount of their income on care costs, even if their monthly income is above the Medicaid income limit. Another way of describing Medically Needy Medicaid is to say that an applicant becomes eligible if the difference between their monthly cost of care and their monthly income is less than a specific amount set by the state.
For example, if the Medically Needy Income Limit in your state is $600, someone who makes $3,000 per month would need to spend more than $2,400 on medical expenses to be eligible for Nursing Home Medicaid despite earning more than the monthly income limit for Medicaid.
Miller Trusts or Qualified Income TrustsAnother option is Miller Trusts or Qualified Income Trusts , which can get complicated but would be described basically as special accounts for someone to deposit income that put them over the Medicaid limit. Money in the trust would not count toward eligibility and would only be accessible by the applicant for specific purposes. The trust is managed by someone who is not the Medicaid applicant and can be used to pay for medical expenses not covered by Medicaid. Not every state allows for Miller Trusts or QITs.
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