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 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:
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
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.
