What is the point of Medicare?

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and why do patients need to stay a certain number of days in the hospital to get it?

Are most people in nursing homes on medicare?

are we doing school work again??

Guess so. One would be surprised at the number of nurses who do not understand how Medicare/Medicaid functions. Or the rules governing eligibility or the amount of assets one can have. Or what the co-pays are and what governs length of stay, to name a few things. Not even are senior citizens know everything they are entitled to or how their retirement health insurance benefits work. And forget the retired military. That is a whole other terror.:devil:

GrannyRN65

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Specializes in COS-C, Risk Management.
Home Health is limited to 35 hours a week. This includes everyone, aide, nurse, PT, OT.

GrannyRN65

Would love to know where you found this. I've been a home health nurse for years and have never run into a limit of 35 hours per week for Medicare-paid home health care. Medicare pays home health a flat fee per episode based on OASIS assessment of the patient and therapy utilization, not by hours.

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Current (December 2010) issue of Consumer Reports has a pretty good piece on Medicare. It is not complete but does explain how one can navigate the system.

As for the "why" of Medicare, it was created to assist seniors with low to middle incomes pay for healthcare they might not otherwise afford. Without it many simply did without (this was from a time when not all employers offered health and or retiree benefits, and or the persons the law sought to cover were born and or lived through times when there was really nothing besides one's life savings to depend upon).

Anywho, as orginally configured Medicare was a good deal for hospitals, doctors and such. Reimbursement rates were high, and it paid for beds that would otherwise be empty and or care that wouldn't either be rendered (for lack of means to pay), or paid for if given (same). IIRC, hospitals and others were at one point allowed to make up any difference in whatever Medicare (and eventually Medicaid) did not pay by billing insurance companies more.

Several factors are coming together that reveal the short comings of Medicare. For one thing the average life expectancy is increasing. This combined with better and newer medical treatments means seniors are not only living longer on benefits, but their care costs more. To slow the growth on the cost end, the federal government has cut back reimbursement rates,to the point they can average

There was also a huge outcry over media coverage of "Medicare Mills" and such high lighting what was supposed to be waste, greed and or persons gaming the system. Each time this happened Congress tightened things up in terms of qualifications, payments and such, and yet the programs still leak funds by the millions each month.

Like SSI, Medicare was never meant to be a seniors sole support, but an added layer to "keep the wolf" from one's door. Priviate savings, insurance (one's own or employers/retirement plan) and so on were supposed to even things out.

What is coming is the perfect storm that will occur when baby boomers start to claim benefits, whilst their long lived parent's generation is also by and large still around. In short there is going to be a huge expansion of those entitled to Medicare, and no one is sure whom is going to pay for all this.

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Would love to know where you found this. I've been a home health nurse for years and have never run into a limit of 35 hours per week for Medicare-paid home health care. Medicare pays home health a flat fee per episode based on OASIS assessment of the patient and therapy utilization, not by hours.

Since 2009, every year,in November, I receive an update from the feds regarding any changes in coverage, increases or decreases. Prior to 2003 I would request publications from Medicare, regarding the same information. Yes, you do get paid a flat fee to cover an episode. And if you furnish services and come in under the fee, you do not have to return that money. In essence, you get to keep it without having to furnish the service. However, if you have a patient that requires more then the episode pays for, you eat the cost. One can say it all works out in the end. The thirty five hours is based on the flat fee schedule. If one follows generally accepted guidelines, one does not exceed thirty-five hours.

My SO has a niece, living in Brooklyn, who has been receiving home health care for fifteen years. She has a home health aide for twelve hours per day, seven days a week, fifty-two weeks a year. She is covered by Medicare/Medicaid. I have looked at her copy of her bills, which she is entitled to, even if tax payers are paying the freight. Althought Medicare pays a flat fee, they are billed for four hours a day, adding up to twenty-eight hours a week. When Medicare changed to the flat fee, the home health agency tried to discontinue her services and have her addmitted to a nursing home. She was party to a class action suit, bought by the MS Association, which they won, on behalf of MS patients. NYS Medicaid pays for the other eight hours a day.

I have some sympathy for home health, I have a greater sympathy for patients who want to remain in their own homes, instead of being shipped to a nursing home. Home based care is much cheaper then nursing home care. What bought about the flat fee schedule was the greed of hospitals, home health agencies, and nursing homes to soak every last dime from Medicare. I was a student when Medicare first came into existence. I have watched as providers and greed have cost the tax payers so much money. I have taken part in investigations into fraud and abuse, by physicians, facilities and agencies. And I have testified at trials and watched wrong doers go to prison. I reveiw every payment that Medicare makes on my behalf. I provided information, in 1997, to the FBI, in regards to HCA and Rick Scott CEO:devil:. Unfortunately, in January he will be my new Governor:mad:-I didn't vote for him.:yeah:

GrannyRN6

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Specializes in COS-C, Risk Management.

I didn't vote for him either. It will be interesting to see how it all plays out.

I have still never seen anything that indicates that traditional Medicare only covers 35 hours per week. And actually, few patients on traditional Medicare will receive anything even approaching 35 hours of care per week. If you can point me to a publication, I would appreciate it. Perhaps your niece has a Medicare Advantage plan that functions more like an HMO, but her home health aide services are surely covered under Medicaid. Medicare does not cover non-skilled care provided without a skilled need such as nursing, PT, or ST. Medicare home care has always been intended to be a short-term solution, not for custodial care, even before PPS was instituted. It was designed to teach/train the patient or a caregiver to be as independent in the home as possible, not to provide long-term care in the home. However, some states do cover long-term home care under Medicaid and waiver programs and they do a great job of keeping people out of long-term care facilities. Sadly, most states have not yet come to the conclusion that warehousing people is not more cost-effective than allowing them the freedom of their own homes with some supportive care.

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I didn't vote for him either. It will be interesting to see how it all plays out.

I have still never seen anything that indicates that traditional Medicare only covers 35 hours per week. And actually, few patients on traditional Medicare will receive anything even approaching 35 hours of care per week. If you can point me to a publication, I would appreciate it. Perhaps your niece has a Medicare Advantage plan that functions more like an HMO, but her home health aide services are surely covered under Medicaid. Medicare does not cover non-skilled care provided without a skilled need such as nursing, PT, or ST. Medicare home care has always been intended to be a short-term solution, not for custodial care, even before PPS was instituted. It was designed to teach/train the patient or a caregiver to be as independent in the home as possible, not to provide long-term care in the home. However, some states do cover long-term home care under Medicaid and waiver programs and they do a great job of keeping people out of long-term care facilities. Sadly, most states have not yet come to the conclusion that warehousing people is not more cost-effective than allowing them the freedom of their own homes with some supportive care.

Pipe:

https://www.cms.gov/cmsforms/downloads/CMS671.pdf

http://www.connecticuthomecare.org/professionals-detail.php?title=Medicare+Home+Health+Care+Rules&id=5

http://www.medicare.gov/publications/pubs/pdf/10969.pdf

http://www.kff.org/medicare/7240/medicare.cfm

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Specializes in COS-C, Risk Management.

I followed your links and think I understand the confusion.

The first is an application for a long term care facility for Medicare and Medicaid. In this situation, Medicare pays for skilled nursing care following a qualifying hospital stay. For long-term care, Medicare pays for the services of a physician, podiatrist, and all the usual associated costs that Medicare covers, but not the long-term care (bed and board) portion. Medicare does not pay for non-skilled care.

The second link is for the Connecticut Home Care Association's Visiting Nurse Association website. See the section that indicates what Medicare covers--skilled services of an RN, PT, ST with the expectation that the patient will improve, not non-skilled care for stable patients. The 35 hours per week is not an indication that Medicare will provide coverage for patients who need 35 hours per week of skilled care as most agencies will not provide that much care under Medicare payment, they would go broke doing so. The 35 hours part is to indicate to discharge planners that if the patient needs 35 hours per week of skilled care (say because they're on a vent or something similar), then the patient would clearly not be appropriate for Medicare Home Care. It does not mean that agencies are obligated to provide care up to 35 hours per week, rather that the cutoff for being "intermittent" is 35 hours per week. All other Medicare criteria must be met, including that the care must be reasonable and necessary.

The third link is for the Medicare Home Health Benefit Policy Manual. If you scroll to page 6, you'll see that the 35 hours statement is used to determine if a patient meets the criteria for "intermittent" care. It is not intended to mean that a patient is entitled to nor will receive 35 hours of care per week. Agencies are not reimbursed for hours of care but for episodes of care and no agency will be able to provide 35 hours of care per week and stay afloat, the reimbursement just isn't there. See page 8, which outlines the services that are covered by Medicare Home Health Benefit, they require a skilled service that is reasonable and necessary for the patient's condition. See page 10 for the services that are not covered, namely non-skilled services such as housekeeping or home health aide services if that is the only care needed.

The fourth link is to the Kaiser Foundation's interpretation of Medicare rules and is a little dated with a publication date of 2005. However, if you'll scroll down about 2/3 of the way to the section "What are some gaps in Medicare's benefits package?" you will see that personal assistant and institutional services are not covered by Medicare. This has not changed. These services may be covered by Medicaid if the beneficiary qualifies.

Grannyrn65, perhaps your niece is covered by Medicare for physician costs and Medicaid for non-skilled costs, but it's very clear that Medicare does not cover non-skilled services.

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