Nursing home is telling us Medicare will stop paying for home health if patient no longer needs PT. Who's right? - AgingCare.com

Nursing home is telling us Medicare will stop paying for home health if patient no longer needs PT. Who's right?

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My Mom is in a Skilled nursing rehab doing PT every day. She is planning to go home and we have asked her Dr. to order the maximum amount of home health, which includes PT. We plan to continue PT at home as long as Mom continues to make progress. According to Medicare, they will continue to pay for home health EVEN if Mom no longer can receive PT because she has plateaued and is no longer making progress. She will continue to qualify for home health because she still would meet the criteria of needed "Skilled Nursing even on a part time basis" as long as her Dr. keeps ordering it every 60 days. Who's right? Medicare or the Nursing Home staff?

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Thanks everyone for all the input. My Mom has reached her paid 100-day stay under Medicare on 12/26/17. She is not fully able to transfer by herself and so we are very concerned. Her dr. is willing to prescribe the maximum amount of home health, and she will need as much help as she can get. She was homebound before she even went into the rehab hospital, so we all do think she qualifies for the maximum home health. Again, thanks for your input. Fingers crossed here. / tbrown62
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The purpose of home care is to stabilize the patient at home by providing education to the patient and family so they can manage on their own in their home with family support, usually after an “acute” event.

It’s very rare an episode goes over 60 days. Something like a wound vac would qualify. But I guarantee if the Skilled staff doesn’t think your mother needs it, Medicare will deny it, because the professionals taking care of the patient have to provide medical justification to Medicare for approval. They can’t make up documention because you may want her to have more. 

If the person can’t manage, then the decision will have to be made with the family, PCP and team to have them placed in a SNF. 

I was a home care RN for 3 years pretty recently. If your mother makes progress to be able to use a walker or an assist device safely in her home, they have to work toward discharge as the patient has reached the goals the staff & her doctor have for her. Same for skilled nursing- if there is a skilled need (wound care comes to mind again) then we’d come in to do it but if it became too long a period then the person would go to rehab or a SNF until they got well enough to go home. And unfortunately, it’s a staffing issue. If the home care agency just got a person in a MVA, or a severe stroke that needs their family to be taught how to help her bathe, re-teach them to walk, etc, those resources will be sent there. 

And, your mother will have to be considered home bound which means only able to go out to the doctor, church, etc. with assistance. No hairdresser, no grocery shopping, no out to see her friends. 
 
I wouldn’t count on more than one 60 day period. I would have a “plan B”. If she does well before the 60 days are up, they will discharge her earlier.

I don’t know your mom’s diagnosis either, and that will definitely effect how much care she will need. 

Good luck to you!

Who’s correct? Too soon to tell. But if the nursing home staff already think your mother has reached her potential then I wouldn’t count on Medicare paying for very long. Her secondary may not pay either. And your mom will be responsible for the 20% Medicare doesn’t cover for home care. It’s a good thing she is doing so well! 
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Please note if your mother REFUSES PT/OT etc. or refuses a home health aide's services, the home health care can be discontinued as failure to comply even if doctor prescribes.
Another publication resource
medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care
"How Medicare pays for home health care
Medicare pays your Medicare-certified home health agency one payment for the covered services you get during a 60-day period. This 60-day period is called an “episode of care.” The payment is based on your condition and care needs.
Getting treatment from a home health agency that’s Medicare certified can reduce your out-of-pocket costs. A Medicare certified home health agency agrees to:
■ Be paid by Medicare
■ Accept only the amount Medicare approves for their services
Medicare’s home health benefit only pays for services provided by the home health agency. Other medical services, like visits to your doctor or equipment, are generally still covered by your other Medicare benefits.
Look in your “Medicare & You” handbook for information on
how these services are covered under Medicare. To view or print this booklet, visit Medicare.gov/publications. You can also call 1-800-MEDICARE (1-800-633-4227) if you have questions about your Medicare benefits. TTY users can call 1-877-486-2048.
Medicare covers at home
● Physical therapy, occupational therapy, and speech-language
pathology services: Your therapy services are considered reasonable and necessary in the home setting if:
1. They’re a specific, safe, and effective treatment for your
condition
2. They’re complex such that your condition requires services
that can only be safely and effectively performed by, or under
the supervision of, qualified therapists
3. Your condition requires one of these:
■ Therapy that’s reasonable and necessary to restore or
improve functions affected by your illness or injury
■ A skilled therapist to safely and effectively establish a
program and/or perform therapy under a maintenance
program to help you maintain your current condition or to
prevent your condition from getting worse
4. The amount, frequency, and duration of the services are
reasonable
● Home health aide services: Medicare will pay for part-time or
intermittent home health aide services (like personal care), if needed to maintain your health or treat your illness or injury. Medicare doesn’t cover home health aide services unless you’re also getting skilled care. Skilled care includes:
■ Skilled nursing care
■ Physical therapy
■ Speech-language pathology services
■ Continuing occupational therapy, if you no longer need any of the above
“Part-time or intermittent” means you may be able to get home health aide and skilled nursing services (combined) any number of days per week, as long as the services are provided:
■ Fewer than 8 hours each day
■ 28 or fewer hours each week (or up to 35 hours a week in some limited situations)
The home health agency must give you a written notice called an “Advance Beneficiary Notice of Noncoverage” (ABN) before giving you a home health service or supply that Medicare probably won’t pay for because of any of these:
■ The care isn’t medically reasonable and necessary.
■ The care is only nonskilled, personal care, like help with
bathing or dressing.
■ You aren’t homebound.
■ You don’t need skilled care on an intermittent basis.
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This is what I found regarding home health care using Medicare.

medicare.gov/coverage/home-health-services

Medicare doesn't pay for:  24-hour-a-day care at home.... Meals delivered to your home.....Homemaker services.....Personal care.
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My mother received home health and PT for many years.(Paid for by traditional Medicare) She lived alone, was home bound, had CHF needed help with her bath.
There are people on this site who truly believe Medicare will not provide.

My experience has been different. 

I’ve been utilizing their services for about 10 years now and traditional Medicare pays.
( not advantage plans- I have no experience with them).

What I would recommend is that you use the Medicare.gov website and look up HH companies in your area. (Unless you have one in mind already). Remember they are for the most part small businesses and while they are licensed the same, some are ran better than others and I understand there are state differences.
Call a couple and see if they provide the service you are looking for. They will work with your Drs office to keep the HH going if it is appropriate. 

HH was tremendously helpful for my mom. My aunt (91) uses the same HH services. Has had them for about five years now.
The RN comes in every six weeks and recertifies that aunt still needs the services. The request is faxed to the dr who signs off. The dr gets paid for overseeing the care as well as the HH agency and the Pt.
We sometimes rotate PT and OT. 

You will need to monitor the HH to make sure your mom is comfortable and cooperative and that the HH is dependable and provides the services promised.
The CNA who bathes my aunt is a lovely person who also cared for my mom years ago. She baths, shampoos, helps with dressing, changes the linens. 

No agency is perfect. Nurses come and go but for the most part I have been extremely pleased with the HH I work with.

The one I have also has a hospice division. Keep that in mind as you interview. We didn’t choose ours based on that but it’s nice to already know the administrative staff should that be a need in the future. 

There is a lot of confusion around services provided by Medicare, even amongst health care providers. If your mom ONLY needs PT your circumstance might be different from my family. 

My aunt has balance issues. So she qualifies based on that for pt and a bath aid. 

Under no circumstances would I suggest you have her leave rehab before she has completed the services they provide. Stay in rehab has long as Medicare will pay. When she gets home she needs to be able to function.
 The PT from home health is usually a couple of times a week. The therapy at the rehab is daily and will enable her to progress faster. Don’t allow her to rush through that portion. Take it in stages. Hospital. Rehab. Then home. ( assuming the rehab is a good one). 

My mother always completed her rehab stay and then cane home to HH and at-home rehab. 

Good luck and come back and tell us how it’s going. 

We learn from one another.
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