Medicare and home care

[Anonymous]

My elderly mother is having her regular freak out about the cost of my debilitated dad’s home care. I don’t blame her as the cost is shockingly high, but I think she is deluded about Medicare.

My dad has advanced Parkinson’s, is on a feeding tube, and can manage neither the feeding or his meds on his own. He cannot be left alone (dementia, huge fall risk) and my mom is too old and decrepit herself to care for him much. We have nurses come in 12 hours a day as no aide was willing to deal with the feeding tube (and meds which must be given through the tube) which is seen as “medical” care.

My mother thinks he could somehow be eligible for the 28 hours or whatever it is of intermittent, part-time home nursing care benefit under Medicare. Like, Medicare would pay for 28 hours every week and we’d pay for the rest.

I told her that 28 hour thing is for PT and OT and temporary visiting nurses, like after a hospitalization, and not for ongoing care of the kind he needs. The Medicare website says that people who need more than part time care are not eligible for this.

If I’m wrong I’d love to know! But if Medicare would actually pay for 28 hours a week of home eldercare for homebound people with dementia, etc, I feel like I would have heard of it. Am I wrong? Is there any source I could go to for the definitive answer on this that would convince my mother and make her accept that care at home will be totally on our dime?

[Anonymous]

I don’t know, but your local SHIP office might be able to provide helpful. In Montgomery County, MD, the JCA has SHIP guidance specialists.



https://aging.maryland.gov/Pages/state-health-insurance-program.aspx

[Anonymous]

Hi OP, I unfortunately DO know all about this mythical 28 hours per week of home health aide that Medicare will pay for, under certain conditions.

Medicare will only pay for some home health aide care, if your patient requires skilled nursing care, O/T or P/T. It sounds like possibly a case could be made for that for your father.

However, even if Medicare agrees to pay for it, you would need to find a home health care agency who participates with Medicare who is willing to provide the staffing for this, and that's where the problem lies. They just won't do it. The most I have heard of people getting (people with ALS) is a few hours a week of home health care. And the process to recertify every 6-8 weeks is time consuming as well.

From what I can figure out, the reason Home Health Care agencies won't staff the home health aides for more hours has to do with how Medicare pays them. If your dad's doctor prescribed him in home skilled nursing, O/T, or P/T due to his medical condition, then Medicare pays the home health agency a certain amount of money for that 6 or 8 week period, depending on how debilitated your dad's condition is. They get more money the more he needs basically - but it's still just in the $2000-$3000 range, mostly.

They then provide the services, so obviously there's a huge incentive NOT to provide all 28 hours of home health care. It comes out of their profit.

We need a new system where the home health companies get paid if they provide the services but apparently that led to a lot of fraud.

If you want to do a deep dive into the ins and outs of this, look into the Center for Medicare Advocady's recent Jimmo Symposium:

https://medicareadvocacy.org/center-symposium-on-the-jimmo-settlement/#:~:text=This%20virtual%20meeting%20brought%20together,we%20can%20do%20about%20it.

[Anonymous]

Anonymous wrote:

From what I can figure out, the reason Home Health Care agencies won't staff the home health aides for more hours has to do with how Medicare pays them. If your dad's doctor prescribed him in home skilled nursing, O/T, or P/T due to his medical condition, then Medicare pays the home health agency a certain amount of money for that 6 or 8 week period, depending on how debilitated your dad's condition is. They get more money the more he needs basically - but it's still just in the $2000-$3000 range, mostly.

They then provide the services, so obviously there's a huge incentive NOT to provide all 28 hours of home health care. It comes out of their profit.

We need a new system where the home health companies get paid if they provide the services but apparently that led to a lot of fraud.

PP again responding to myself.

If the home health companies say they cannot staff the full 28 hours of home health care for a patient who otherwise qualifies, I think that they should be required to pay the family caregiver the amount they would have paid their employee instead.

[Anonymous]

OP, this article is old, having been written in 2015, but it says that enteral feeding of more than 26% of your calories per day should count as "Skilled Nursing" under Medicare rules at the time.

https://medicareadvocacy.org/medicare-coverage-of-skilled-care-nine-services-that-are-skilled-by-definition

[Anonymous]

Thank you so much, PPs, that is super helpful and makes a lot of sense.

But even if I could find a Medicare approved agency willing to staff 28 hours of skilled nursing, wouldn’t he be ineligible for this care under Medicare because he needs this care much more than part time or intermittently? Although it seems like if people with ALS were eligible then it might be possible that his condition would be as well, given that he is 100% on enteral feeding that he cannot manage alone.

Anyway thank you for your insights. I really do appreciate it.

[Anonymous]

Anonymous wrote:Thank you so much, PPs, that is super helpful and makes a lot of sense.

But even if I could find a Medicare approved agency willing to staff 28 hours of skilled nursing, wouldn’t he be ineligible for this care under Medicare because he needs this care much more than part time or intermittently? Although it seems like if people with ALS were eligible then it might be possible that his condition would be as well, given that he is 100% on enteral feeding that he cannot manage alone.

Anyway thank you for your insights. I really do appreciate it.

I don’t think that’s the problem, ya just that the agencies won’t provide he care. https://medicareadvocacy.org/issue-brief-medicare-home-health-coverage-reality-conflicts-with-the-law/

[Anonymous]

It depends on the state.

[Anonymous]

Anonymous wrote:It depends on the state.

Not for Medicare.