October 24, 2005
MEDICARE AND MEDICAID COVERAGE FOR HOME HEALTH CARE SERVICES
By: Robin K. Cohen, Principal Analyst
You asked what type of home health care might be available to someone who (1) has been residing in a nursing home for several months and (2) qualifies for both Medicare and Medicaid. You also wanted to know if either program dictates what the value of the beneficiary's motor vehicle can be as a condition of eligibility.
The Medicare program offers home health care services to program beneficiaries provided they meet certain nonfinancial eligibility criteria (e.g., they must have a medical need and the home health agency must be Medicare-certified). Medicare will not pay for 24-hour care in the home. Rather, it generally pays for short-term, intermittent care.
In general, Medicaid is the payer of last resort: someone needing home care must exhaust all other sources of insurance before Medicaid will pay. Historically, the Medicaid-funded portion of the Connecticut Home Care Program for Elders (CHCPE) has provided supplemental care to individuals for whom Medicare coverage was not quite adequate. Recently, however, the federal government has told the state that Medicaid should not be paying for this coverage.
Medicare imposes no asset limits on program beneficiaries. Medicaid does and these include limits on the number and value of vehicles. In general, one vehicle is completely excluded if it is needed for medical appointments and other trips. If it is not, or the applicant has additional vehicles, their fair market value is limited to $4,500, and any value above that is applied to the program's liquid asset limit, which varies based on the Medicaid coverage group the recipient is in.
A new state project designed to help individuals move from institutional to community settings may provide additional resources to this individual's family.
MEDICARE COVERAGE FOR HOME HEALTH CARE
According to the Center for Medicare Advocacy (CMA), Medicare enrollees can qualify for certain home health care services (skilled nursing care and some health care services for the treatment of an illness or injury) if:
1. their doctor decides they need medical care at home and makes a plan for the care;
2. they need at least one of the following: intermittent (not full time) skilled nursing care, physical or occupational therapy, or speech-language services;
3. they are homebound or normally unable to leave home without assistance (they may leave home for medical treatment, religious services, to attend adult day care, or short infrequent trips for nonmedical purposes); and
4. the home health agency providing the services is approved by Medicare.
If the patient meets the medical needs requirements, Medicare covers the following services:
1. part-time or intermittent skilled nursing care by a registered or licensed practical nurse;
2. part-time or intermittent home health aide services, including help with personal care such as bathing, toileting, or dressing (but only if the patient is also receiving the skilled nursing care and the home health services are part of the home care needed for the illness or injury);
3. physical, speech-language, and occupational therapy for as long as the doctor prescribes it (occupational therapy can be continued even after the patient no longer needs other skilled care);
4. medical social services such as counseling or help in finding resources;
5. certain medical supplies such as wound dressings; and
6. medical equipment such as wheelchairs or walkers.
This home health care is covered by Medicare Part A (or Part B if that is all the patient has signed up for). The patient has no co-pay for these services.
Medicare does not pay for 24-hour home care; it covers only part-time or intermittent home care. “Intermittent” means skilled nursing and home health aide services which, when combined, do not exceed eight hours a day and which are provided for no more than 28 hours per week. If someone needs between 28 hours and 35 hours a week (the program's absolute legal limit), a doctor must certify every 21 days that there is a “finite and predictable end” to the need for the additional care, reports Lara Stauning of the CMA. Otherwise, services are covered for as long as the patient needs them, but the doctor and home health agency staff must review the plan of care at least once every 60 days.
Medicare will not pay for home-delivered meals; homemaker services such as cleaning, shopping, or laundry; and personal care by home health aides if that is the only service the patient needs. But a dually eligible (Medicare and Medicaid) person could potentially get these services from the Connecticut Home Care Program for Elders (CHCPE) (see below).
Unlike other Medicare benefits, which generally cover only 80% of the approved charge, the Medicare fee-for-service plan pays the full approved amount for all covered home health visits. But the patient could be charged for 20% of the approved amount for covered medical equipment or the full amount of services and supplies that Medicare does not pay for. Patients in a Medicare HMO would receive at least the same coverage, but they might be limited to choosing only home health agencies that have a contract with the HMO. Someone who is dually eligible would generally not have to pay the 20%.
MEDICAID HOME HEALTH OPTIONS
Patients who do not meet the medical conditions for home health care under Medicare but still need such services, or those who exhaust their Medicare coverage, may be eligible for home care under the Medicaid-funded portion of the CHCPE, a Medicaid waiver program that provides coverage for medical as well as nonmedical home care services
The Department of Social Services' (DSS) Alternate Care Unit runs this program and applications are made at local DSS offices. This unit determines whether someone is functionally eligible for the program and refers those who are to a regional access agency (Connecticut Community Care, Inc. in eastern Connecticut), which helps create a care plan and contracts with local home health care agencies for the services. (These agencies can also help coordinate Medicare and Medicaid home care services for these individuals.
Although many dually eligible individuals are eligible for non-waiver home health care services (i.e., State Plan coverage), according to DSS, CHCPE is the more typical Medicaid coverage.
Once Medicare coverage is exhausted, or if an individual needs nonmedical services, such as help with chores, he may qualify for additional home health care through the CHCPE. This program provides an array of home and community based services to frail elderly who are at varying degrees of risk of needing institutional care.
CHCPE consists of three categories: Type 1, Type 2 and Type 3, Type 1 provides state-funded, limited care for moderately frail elderly who have one or two critical needs. There is no income limit for these services and assets are limited to $19,020 for an individual and $28,530 for a married couple. Type 2 offers intermediate home care for very frail elders whose income and assets are above the Medicaid limits. Type 3 provides extensive, Medicaid-covered care for frail elders who would otherwise require skilled nursing care.
Once enrolled in the program, the access agency helps create a care plan. The plan has cost limits, which are tied to the cost that the state would incur if the person were institutionalized; these limits rise as the level of need rises. For Type 1, the care plan must be less than 25% of the average monthly nursing home cost. For Type 3, the monthly limit is 100% of the nursing home cost.
In addition to traditional home health services, the program pays for nonmedical services such as homemakers, companions, and adult day care. But the cost of any nonmedical services may not exceed 60% of the average Medicaid nursing home costs. CMA notes that under these caps, 24-hour care would never be considered to be cost effective, unless the individual had other resources available to him, such as family funds.
MOTOR VEHICLE LIMITS — MEDICAID
State regulations set certain limits on the amount and types of assets Medicaid recipients may keep. With respect to motor vehicles, the regulations exclude totally a motor vehicle if it is (1) needed for work, (2) needed for medical treatment of a specific or ongoing medical problem, or (3) has been modified for operating by, or transporting of, a person with a disability. This applies to an individual as well as to a couple living together.
If no vehicle is excluded, DSS must exclude up to $4,500 of the vehicle's fair market value. The remaining fair market value is counted towards the overall asset limit. If there is a second vehicle, the Medicaid applicant's or beneficiary's equity in the vehicle counts toward the asset limit, and the $4,500 exclusion is applied in a way that is most advantageous to the recipient (DSS Uniform Policy Manual, Sec. 4030.35).
These limits are the same whether the beneficiary is receiving CHCPE services or regular Medicaid services. (The income and asset limits for the former program are more generous than the latter's.)
NURSING FACILITY TRANSITION GRANT
A new DSS project to help individuals living in nursing homes who want to move into the community with the supports they need may also interest you. The Nursing Facility Transition Grant, a three-year grant program, may offer this family assistance.