MEDICARE AND HMO'S

In the United States, Medicare is a national social insurance program, administered by the U.S. federal government since 1965, that guarantees access to health insurance for Americans aged 65 and older and younger people with disabilities as well as people with end stage renal disease (Medicare.gov, 2012) and persons with Lou Gehrig’s Disease

As a social insurance program, Medicare spreads the financial risk associated with illness across society to protect everyone, and thus has a somewhat different social role from for-profit private insurers, which manage their risk portfolio by adjusting their pricing according to perceived risk.

DEMOGRAPHIC

• In 2010, Medicare provided health insurance to 48 million Americans
• In 2009, Medicare enrolled 2.9million people in Texas
• In 2010, Medicare disbursed $521.1billion to providers across America
• In 2010, Medicare disbursed $7.1billion directly to Home Health Agencies across America
• In 2010, Medicare disbursed $60.3billion to Managed Care Institutions

Source: U.S. Centers for Medicare and Medicaid Services

COVERAGE

Medicare Part A: Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies medically necessary to treat a disease or condition. Part A disburses funds to the following providers:

• Skilled nursing facility care
• Nursing home care (as long as custodial care isn't the only care you need)
• Hospice
• Home health services
• Hospital care

Medicare Part B: This covers 2 types of services which are:

• Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
• Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

Some Home Health Agencies (HHA) have licenses to cover some medical necessities under the Part B program which are “Durable Medical Equipment” (DME’s) and Medical Supplies. The following are a list of things covered under the Part B program:

• Clinical research  
• Ambulance services
• Durable medical equipment
• Mental health
• Inpatient

Medicare Part C: Part C also known as “Medicare Advantage” plans allows beneficiaries to choose to receive all of their health care services through a provider organization.  These plans may help lower their cost of receiving medical services, or enable them get extra benefits for an additional monthly fee.  A “member” must have both Parts A and B to enroll in Part C.

Medicare Part D: Part D (prescription drug coverage) is voluntary and the costs are paid for by the monthly premiums of “enrollees” and Medicare.  Unlike Part B in which members are automatically enrolled and must opt out if they do not want it, with Part D members have to opt in by filling out a form and enrolling in an approved plan.

As you journey into Home Health Care, the term HMO and Medicare HMO will be used interchangeably and most times incorrectly. Here you will have the opportunity to differentiate between both of them and see the relationship between these 2 plans and Home Health Agencies that are contracted with them.

The Balanced Budget Act of 1997 (BBA) established a new Part C of the Medicare program, known then as the Medicare+Choice (M+C) program, effective January 1999. As part of the M+C program, the BBA authorized “CMS” to contract with public or private organizations to offer a variety of health plan options for beneficiaries, including coordinated care plans (such as health maintenance organizations (HMOs), provider sponsored associations (PSOs), and preferred provider organizations (PPOs)), Medicare Medical Savings Account (MSA) plans, private-fee-for-service (PFFS) plans, and Religious Fraternal Benefit (RFB) plans. These health plans provide all Medicare Parts A and B benefits, and most offer additional benefits beyond those covered under the Original Medicare program.

Traditionally, Medicare and HMOs were separate entities and each played a defined role in health care in the United States. Changes in Medicare policy have brought the two together. Combined, they provide a particular way of paying for Medicare supported health care.

                                          WHAT IS AN HMO?

HMO stands for Health Maintenance Organization. HMOs are managed care organizations (MCO) that provide a form of health care coverage. HMOs coordinate a patient's health care according to the regulations of the patient's selected health plan. Some of the following are examples of HMO’s popular in Texas:

• United Health Care (UHC) formally known as Evercare
• CIGNA also sometimes called Carecentrix
• Blue Cross Blue Shield
• Superior Health Plan
• Molina
• Homelink
• Amerigroup
• Aetna

Healthcare “providers” are contracted with the HMO to provide care as outlined by the HMO's guidelines for each health care plan. In exchange, the HMO lists the provider or physician in its list of approved providers thereby directing a steady stream of patients to the providers.

ACCREDITATION

HHAs are required by Federal and State laws to be licensed to operate in the States in which they are registered business entities. There are certain criteria they must meet for them to be eligible to be accredited for the Medicare program. Due to the large number of applications being received for licensure and the increase in Medicare fraud and abuse, the process for obtaining a license has become more vigorous, making the process more rigid for agencies to be certified to operate.

Accreditation Agencies:

·        Community Health Accreditation Program (CHAP)

·        The Joint Commission

·        Accreditation Commission for Health Care, Inc.

CRITERIA

• An applicant for a license must not admit a client or initiate services until the applicant completes the application process and receives an initial license
• A first-time application for a license is an application for an initial license
• An application for a license when there is a change of ownership is an application for an initial license
• A separate license is required for each place of business
•  An agency's place of business must be located in and have an address in Texas. An agency located in another state must receive a license as a parent agency in Texas to operate as an agency in Texas
• An applicant must be at least 18 years of age.

Before issuing a license, DADS considers the background and qualifications of:

·        The applicant;

·        A controlling person of the applicant;

·        A person with a disclosable interest;

·        An affiliate of the applicant;

·        The administrator;

·        The alternate administrator; and

·        The chief financial officer

http://www.dads.state.tx.us/handbooks/lshcssa/B/index.htm#rl97.11

                                            MEDICARE PROGRAMS

As an accredited Medicare Home Health “provider” there are certain things you should know before administering care to your clients. The following questions need to be asked:

• Is my client eligible?
• What coverage does he/she have?
• What services does my client need?

ELIGIBILITY

• Client must be over 18
• Client must be getting services under a plan of care established and reviewed regularly by a doctor
• A doctor must certify that you need, one or more of the following.
• Intermittent skilled nursing care
• Physical therapy
• Speech-language pathology services
• Continued occupational therapy
• Client must be homebound, and a doctor must certify that he/she is homebound

To be homebound means the following:

• Leaving your home isn’t recommended because of his/her condition
• Client’s condition keeps him/her from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person)
• Leaving home takes a considerable and taxing effort

http://www.medicare.gov/Pubs/pdf/10969.pdf

COVERAGE

Medicare covers the following services for patients that are home bound under the Part A and B programs:

• Skilled Nursing
• Physical Therapy, Occupational Therapy, and Speech – Language Pathology Services
• Medical Social Services
• Medical Supplies
• Durable Medical Supplies (DMEs)

What is not covered under Medicare?

·        24 hours a day care at home

·        Meals delivered to clients at home

·        Attendant Services

                    MEDICARE ELIGIBILITY: PROVIDERS VS MEMBERS

As earlier mentioned, providers and members under the Medicare programs both need to be eligible to administer (HHA) and receive (clients) home health services under the Medicare program.

In recent times, HHA agencies have been penalized for providing services to clients who do not meet the criteria required by the Center for Medicare & Medicaid Services (CMS).

Experience as shown that providers tend to make promises to clients that they are cannot honor because these clients although they have Medicare, they do not have coverage for these services.

Providers need to ensure that there is medical necessity and the client meets the following criteria:

Over 65: For individuals who have paid Medicare taxes until they reach 65, they are automatically enrolled into the Part A program.

Under 65 (disabled): A client may be eligible for Part A as a result of his/her disability.

Widow/Widower between 50 and 65: a widow or widower between the ages of 50 and 65, you may also be eligible to apply for Medicare if you do not receive disability benefits, but you receive any other Social Security benefit.

Special Enrollment: You may become a Medicare beneficiary if you, a dependent child or your spouse suffers kidney failure requiring dialysis or a transplant.