Is Visiting Angels Covered by Medicare?

1. Introduction

However, if this care is not directly tied to skilled care for acute or chronic conditions, Medicare’s benefits are very limited. This is where there is often a great deal of confusion for Medicare beneficiaries. Many think that all homecare is covered by their benefits. However, it’s important to distinguish traditional home health care (which includes skilled nursing care and therapy services) and non-medical homecare.

Visiting Angels, a national private duty network, says it provides “assistance” with bathing, dressing, walking, transfer assistance, medication reminders, and incontinence care. This is what people considering nursing home care often need the most. And studies show that people recover more quickly at home, with less risk of infection.

Medicare is the leading health insurance program for US citizens age 65 and older. It also includes benefits for those with long-term illnesses, like in-home care from Visiting Angels. It’s important to understand how Medicare can help with these services. Planning to live independently, living at home for the rest of your life, is a goal for most of us. However, as medical conditions progress, many seniors who once were independent find they are no longer able to care for themselves.

2. Understanding Medicare Coverage

Response not found The section explains different parts of Medicare coverage and possible Visiting Angels services that can be covered under them. It goes in depth into the eligibility criteria and services covered in each part. It also provides an overview of the coverage limits and services the beneficiary can expect. It does an excellent job at explaining various Medicare plans in a way that is understandable to the consumer. It goes one step further than most other websites on Visiting Angels Medicare coverage by providing information on Medicaid coverage and other state programs. It’s important to have this information in full view for anyone considering long-term care services for their loved ones. Low This site was thorough, yet understandable source for Medicare coverage information. The site is simple to navigate and gets right to the point on all issues. A bit of the information can be left to interpretation but overall this site is a very useful resource for anybody beginning their search for long-term care for a loved one. The information will help the user understand what they can expect to pay out of pocket when using Visiting Angels home care services.

2.1. Medicare Part A

Medicare Part A is hospital insurance. This helps pay for inpatient care in a hospital or skilled nursing facility following a hospital stay. This is also your coverage for hospice care and some home health care. Perhaps you are considering surgery or have just been involved in an unfortunate accident that leads you to require some sort of hospitalization or nursing care following a hospital stay. This is definitely the right time to take advantage of your Medicare Part A coverage. Any other services that are deemed unnecessary, in the eyes of Medicare, will not always be covered. For example, the most important aspect of the skilled care needed in order to qualify for Medicare coverage is for the trained professional to perform services that only they can do. (Ryskina et al.2020)(Freburger et al.2022)(Prusynski, 2021)(Valverde et al.2021)(Barnett et al.2020)(El-Nahal, 2020)(Joynt et al.2021)

Medicare coverage is important for those who are aging into Social Security, those retiring from a job that provided them with health insurance coverage, and those who are considering leaving employment. This is also an important factor to consider for people who are 65+, disabled or determined to have renal failure. It is imperative that you understand what Medicare will pay for, and what it will not. Do your research and understand the rights to your Medicare coverage before spending a lot of money on something that could otherwise be covered under Medicare.

2.2. Medicare Part B

If you have Part B, it covers 100% of the cost of medically necessary clinical diagnostic laboratory services. This means you pay nothing for the services. Medicare Part B is the part of Original Medicare that covers doctor and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Medically necessary services are those services and supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.

Medicare Part B is the part of Original Medicare that covers doctor and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

2.3. Medicare Advantage Plans

People with Advantage Plans still retain their Medicare eligibility and have the right to leave the plan during specified times within the first year and re-enroll in the same Medicare supplemental policy that they were previously enrolled in. If that is not possible, then there are special enrollment periods after the first year. If the particular Advantage Plan is discontinued, the insurance company must offer the customer another plan, or the client will have the opportunity to return to traditional Medicare.

With Advantage Plans, there is a trade-off as not all services will be covered 80%, and there may be different out-of-pocket expenses and co-pays. It is possible that coverage for some services may be better, the same, or worse than traditional Medicare. Generally, services are still covered in full if you stay in-network.

There are many different Advantage Plans available in the United States, but only specific ones are available in certain areas. In the past, some Advantage Plans were actually HMOs, but that has changed, and recipients no longer have to go through a primary care physician and can go to any doctor that accepts the plan. Consumers should be aware of the rules and coverage of their plan.

Medicare Advantage Plans take the place of Part A and B of Medicare. It is regulated and approved by Medicare but is administered by private health insurance companies. It simplifies the administration of one’s Medicare benefits by being a single plan which provides coverage for hospital care and other services covered by Medicare. Most Advantage Plans also offer coverage for prescription drugs, and many private insurance companies offer additional benefits that aren’t covered by Medicare.

3. Coverage for In-Home Care Services

If the above conditions are met, then the following types of in-home care can be provided and covered by Medicare. These services will be classified as either therapeutic services or skilled care. Any service not classified as a therapeutic service or skilled care, as well as custodial care, will not be covered by Medicare.

3. The care agency providing services must be Medicare certified. Individual providers and registry agencies are not eligible for coverage. This means that coverage is only possible if using a nurse or home health aide from a state-licensed and Medicare-certified agency.

2. The individual requiring care must be under the care of a physician who has established a plan of care. This means that there must be a signed plan of care that is regularly reviewed and updated by the physician.

1. The individual requiring care must be homebound. This means that leaving home is a major effort. If the individual in question attends adult day care or goes to church once a week, this is not considered homebound.

Medicare does cover in-home care services. In fact, in-home care is the only type of long-term care for which Medicare will pay. However, there are certain conditions that must be met for Medicare to pay for in-home care. The following is a list of the requirements for coverage of in-home care by Medicare:

3.1. Eligibility Criteria

In terms of the last point, for something to be considered medically necessary, there must be an underlying medical condition that requires treatment by a doctor and it must be expected to show improvement. If a patient is simply seeking to receive treatment for help with an ADL, but does not have a medical condition that is in need of treatment, then that service is not considered medically necessary. A written order from a doctor may be needed to prove that a certain treatment or service is medically necessary.

At its most basic level, the eligibility criteria for Medicare consists of: – You must be 65 or older. – You must be a US citizen or a permanent legal resident for at least 5 continuous years. – You or your spouse must have worked recently (in the last 10 years) and contributed to Social Security. – You must be seeking care that Medicare considers to be medically necessary.

Quite a number of people believe that Medicare pays for long-term care such as that provided by Visiting Angels. This is not true. Medicare takes care of medical treatment, but it does not pay for help with ADLs (Activities of Daily Living), custodial care, or long-term care.

3.2. Covered Services

Home health aide services. Home health aide services provide specialized supportive care. The HHA services must be part of the skilled treatment plan and require the supervision of a skilled professional. An HHA provides assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) that are necessary to maintain good health and facilitate treatment of the patient’s illness or injury. Schedule restrictions for HHA services stipulate that services cannot be provided if other caregiver support is available, or if the only need is for personal care. Services are intermittent part-time or full-time and are provided in the patient’s home. (Biganzoli et al.2020)(Powers et al.2020)(McCord et al.2020)(Glenton et al., 2021)(Salawu et al.2020)(Ruotsalainen et al., 2020)(Haleem et al., 2021)(Hilty et al.2020)(Marshall et al.2021)

Skilled nursing care. Skilled nursing care is a service provided when a patient needs a registered nurse (RN) or a licensed practical nurse (LPN) to manage, observe, and evaluate care. Skilled nursing care also includes services for teaching and training the patient to be independent with their care.

When Medicare is the payment source, the following services are covered, as they allow the patient to stay at home. Medicare will not pay for services if only personal care or homemaker services are required. There must be a skilled need and the services must be provided by a Medicare certified Home Health agency. Following are brief descriptions of Medicare home health covered services.

3.3. Limitations and Exclusions

For example, if an individual receives home care for 100 days then has a 60-day break from skilled care and then the condition worsens and more skilled care is required, a new 100-day benefit period will be available. If the individual has a break in care of more than 60 days, the law assumes that the individual’s condition has improved and the prior benefits can be renewed. At no time can the individual receive more than 100 days of care in a benefit period. This rule is vastly complex and often misunderstood by policyholders and insurance companies.

If the individual qualifies, Medicare will pay the full cost of the first 20 days of home care. For the 21st through the 100th day, the individual will have a co-payment which is adjusted every year. This is a very important rule. The 100-day period is not tied to a calendar year, it is tied to an individual’s need for a spell of illness. A new spell of illness begins when the individual has not received Medicare-covered skilled nursing care in a hospital or Skilled Nursing Facility for 60 days in a row. A new benefit period is the same as a new spell of illness. The benefit period ends when the individual has not received skilled care for a chronic condition for a 60-day period. Any time after that, the 100-day benefit period is reset and the individual is entitled to a new period of 100 days of skilled care.

Medicare will pay for in-home care only if the individual needing the services qualifies for either Part A or Part B and if the care is considered reasonable and necessary. The fact that a person is homebound is not a requirement. However, it is recognized that it is harder to prove that home care is reasonable and necessary if the individual is not homebound.

4. Alternatives to Medicare Coverage

Private and Long-Term Care Insurance Because Medicare and traditional health insurance will not pay for non-medical home care, health care options may be very important to making in-home care affordable for elderly persons. People whose health conditions are such that they do not yet need to be placed in a nursing home but do need some form of care can benefit greatly from insurance that is supportive of home care. People who already have existing health problems may not be able to purchase long-term health care insurance due to a pre-existing condition clause, yet many others will still be eligible for long-term care insurance. This kind of insurance can cover the cost of a caregiver in the home and may be the alternative to private pay. Always check your specific policy for coverage.

Older Americans Act and state-based programs The Older Americans Act was created in 1965 to provide services to older persons and persons with disabilities. Although anyone may receive services, the programs specifically designed to help the elderly are administered by the Administration on Aging. These state and federally funded programs can not only help the elderly get in touch with someone who can assess their needs in terms of care but also help provide the care itself. This too can help cover some of the cost of in-home care via Visiting Angels.

Veteran’s Benefits The Department of Veterans Affairs is also a sizable source of special elder care benefits, more so than the Medicaid program. Depending on financial need, the benefits can vary. Benefits can be used to supplement other care coverage, like Medicare or Medicaid, and the kind of services provided by the program vary.

It’s always a bit of a challenge figuring out how to pay for in-home elder care with so many different payment options available. While the alternatives below may not entirely make up for the cost of in-home care, they can be helpful. The following alternative options can be used in conjunction with your Medicare or other insurance to cover part of the cost of Visiting Angels services.

References:

Ryskina, K.L., Yuan, Y., Polsky, D. and Werner, R.M., 2020. Hospitalist vs. non-hospitalist care outcomes and costs for Medicare beneficiaries discharged to skilled nursing facilities in 2012–2014. Journal of general internal medicine, 35, pp.214-219. springer.com

Freburger, J.K., Pastva, A.M., Coleman, S.W., Peter, K.M., Kucharska-Newton, A.M., Johnson, A.M., Psioda, M.A., Duncan, P.W., Bushnell, C.D., Rosamond, W.D. and Jones, S.B., 2022. Skilled nursing and inpatient rehabilitation facility use by medicare fee-for-service beneficiaries discharged home after a stroke: Findings From the COMPASS trial. Archives of Physical Medicine and Rehabilitation, 103(5), pp.882-890. unc.edu

Prusynski, R., 2021. Medicare payment policy in skilled nursing facilities: Lessons from a history of mixed success. Journal of the American Geriatrics Society. nih.gov

Valverde, P.A., Ayele, R., Leonard, C., Cumbler, E., Allyn, R. and Burke, R.E., 2021. Gaps in hospital and skilled nursing facility responsibilities during transitions of care: a comparison of hospital and SNF clinicians’ perspectives. Journal of general internal medicine, pp.1-8. springer.com

Barnett, M.L., Maddox, K.E.J., Orav, E.J., Grabowski, D.C. and Epstein, A.M., 2020. Association of skilled nursing facility participation in a bundled payment model with institutional spending for joint replacement surgery. Jama, 324(18), pp.1869-1877. jamanetwork.com

El-Nahal, W., 2020. An overview of Medicare for clinicians. Journal of general internal medicine. springer.com

Joynt Maddox, K.E., Barnett, M.L., Orav, E.J., Zheng, J., Grabowski, D.C. and Epstein, A.M., 2021. Savings and outcomes under Medicare’s bundled payments initiative for skilled nursing facilities. Journal of the American Geriatrics Society, 69(12), pp.3422-3434. nih.gov

Biganzoli, L., Cardoso, F., Beishon, M., Cameron, D., Cataliotti, L., Coles, C.E., Bolton, R.C.D., Trill, M.D., Erdem, S., Fjell, M. and Geiss, R., 2020. The requirements of a specialist breast centre. The Breast, 51, pp.65-84. sciencedirect.com

Powers, M.A., Bardsley, J.K., Cypress, M., Funnell, M.M., Harms, D., Hess-Fischl, A., Hooks, B., Isaacs, D., Mandel, E.D., Maryniuk, M.D. and Norton, A., 2020. Diabetes self-management education and support in adults with type 2 diabetes: a consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Journal of the American Pharmacists Association, 60(6), pp.e1-e18. diabetesjournals.org

McCord, C., Bernhard, P., Walsh, M., Rosner, C. and Console, K., 2020. A consolidated model for telepsychology practice. Journal of Clinical Psychology, 76(6), pp.1060-1082. wiley.com

Glenton, C., Javadi, D., & Perry, H. B., 2021. Community health workers at the dawn of a new era: 5. Roles and tasks. Health Research Policy and Systems. springer.com

Salawu, A., Green, A., Crooks, M.G., Brixey, N., Ross, D.H. and Sivan, M., 2020. A proposal for multidisciplinary tele-rehabilitation in the assessment and rehabilitation of COVID-19 survivors. International journal of environmental research and public health, 17(13), p.4890. mdpi.com

Ruotsalainen, S., Jantunen, S., & Sinervo, T., 2020. Which factors are related to Finnish home care workers’ job satisfaction, stress, psychological distress and perceived quality of care?-a mixed method study. BMC Health Services Research. springer.com

Haleem, A., Javaid, M., Singh, R. P., & Suman, R., 2021. Telemedicine for healthcare: Capabilities, features, barriers, and applications. Sensors international. sciencedirect.com

Hilty, D., Chan, S., Torous, J., Luo, J. and Boland, R., 2020. A framework for competencies for the use of mobile technologies in psychiatry and medicine: Scoping review. JMIR mHealth and uHealth, 8(2), p.e12229. jmir.org

Marshall, A.P., Austin, D.E., Chamberlain, D., Lee-anne, S.C., Cree, M., Fetterplace, K., Foster, M., Freeman–Sanderson, A., Fyfe, R., Grealy, B.A. and Hodak, A., 2021. A critical care pandemic staffing framework in Australia. Australian Critical Care, 34(2), pp.123-131. nih.gov