Insurance Coverage

Understanding Insurance Coverage for Home Health Services

Frequently Asked Questions

How much do I have to pay for home health services?
This will depend on your insurance. Please contact your insurance company for your benefits, co-pays and/or coinsurance for home health services.

How am I informed of what I owe and when will I be billed for these charges?

Elder’s Choice, Inc. will verify your benefits based on the insurance information you and/or your representative provide us with. We rely on Medicare/Medicaid and/or your insurance company to provide us with accurate and timely information regarding your benefits. Based on this information, before we start caring for you, we will inform you verbally and in writing of your estimated financial liability. This information will be provided to you in writing on the Home Care Services Agreement. You will only be billed for these charges after services have been rendered and payment has been received from your insurance company.

Do I need to notify Elder’s Choice, Inc. if my insurance benefits change; EVEN if I am just changing my prescription drug benefits?

Absolutely YES! Providing this information will help ensure we are minimizing your out-of-pocket costs. A change in your prescription drug plan may alter your home health benefits. Please notify your nurse or therapist if you have a change in insurance benefit, or you may call us at 561 – 439 – 2877.

MEDICARE COVERAGE AND ELIGIBILITY

a. Which Home Health Services Does Medicare Cover?

• Part time or intermittent skilled nursing care
• Home health aide services (with skilled care need)
• Physical therapy
• Occupational therapy
• Speech therapy
• Medical social services
• Certain medical supplies
• Certain medications

b. Which Home Health Services are Not Covered by Medicare?

• 24 hour-a-day care at home
• Daily nursing care with no reasonable expected end
• Meals delivered to the home
• Homemaker services, such as shopping and / or cleaning

c. Criteria for Admission

• For patients requiring skilled services (e.g. RN, LPN, PT, etc.), The agency must have orders to provide care issued and signed by a licensed doctor of medicine, osteopathy or podiatry.
• If you are a Medicare recipient you must be homebound – this means that there exists a normal inability to leave the home and leaving the home takes considerable and taxing effort. Also, any absences from the home, for reasons other than to obtain medical treatment, are infrequent and of short duration. Our staff can explain this to you on the initial visit.
• You must be at least 21 years of age and live in Palm Beach, Martin, or St. Lucie counties.
• Your clinical needs can be safely and effectively met in your place of residence.
• You must be able to care for yourself in-between visits or there is a reliable paid or voluntary caregiver available to meet your needs between visits by the agency. We will observe, support and instruct your caregiver to ensure competence and reliability.
• You must be compliant with your care.
• You must need intermittent skilled nursing care, speech therapy, physical therapy, and/or have a continuing need for occupational therapy services.
• You must have a physician who is willing to oversee your care and sign the Plan of Care.
• You must have a face-to-face encounter with the physician who is ordering your care, his physician assistant or nurse practitioner, up to ninety (90) days prior to the home health start of care or within thirty (30) days after the home health start of care and the reason for the visit must be related to the reason for your need of home care.
• Either you or your legally authorized representative must consent to care.
• There must be a reasonable expectation that the patient’s special needs can be met by the services provided to the patient by the Agency. The agency cannot accept patients whose care needs are beyond the scope of care or staff that can be provided by the agency.
• Patients who require non-skilled services, (e.g. homemaker, companion) do not require a physician referral; however a service plan to meet your needs is still formulated with your input.
• Environmental conditions of the patient’s home must allow for adequate treatment of the patient and the safety of staff and the patient. The patient must be able to care for him/herself in between visits from Agency personnel if there is no reliable paid or voluntary primary caregiver available to meet all of the needs of the patient between visits by the agency.
• Patient’s must meet Medicare eligibility requirements (see below).

d. Patient Eligibility Requirements

• In order for home health services to be covered under the Medicare benefit, several criteria must be met.
• The patient must be homebound – this means there exists a normal inability to leave the home and leaving the home takes considerable and taxing effort. Also, any absences from the home, for reasons other than to obtain medical treatment, are infrequent and of short duration.
• The patient must need intermittent skilled nursing care, speech therapy, physical therapy, and/or have a continuing need for occupational therapy services in his or her home setting.
• The patient must have an attending physician who is willing and able to assume full responsibility for the patient’s medical care while receiving home health services.
• The physician must document a face-to-face encounter has occurred where the physician, the physician’s employed physician assistant or nurse practitioner, has actually seen the patient for a related reason for the home care admission up to 90 days prior to the home health start of care or within 30 after the home health start of care.

e. About Financial Responsibility

• Payment for services can be through Medicare, Medicaid, Worker’s Compensation, Veteran’s Administration, state assistance programs, private insurance, or private pay.
• If you are covered by Medicare, there is no deductible and 100% coverage for most home health services. A few items are covered under Medicare Part B and are only covered at 80%. Supplemental co-insurance will cover the remaining 20% or you may be billed for the difference. Any charges for services will be discussed with you prior to the start of care. You will be informed verbally and in writing of all charges for services provided and methods of payment.
• Medicare beneficiaries receiving home health care from our agency may receive periodic statements from Medicare which are NOT BILLS. These statements come from the Medicare insurance company that pays us for the care we give to you. They are intended to keep you informed of the charges being billed to Medicare on your behalf. If you have any questions about these statements when you get them, please let us know.

f. Coordination of Care / Continuity of Care.

Once your doctor provides us with a referral or orders to provide your home care, our agency will perform an assessment of your homecare needs at your place of residence within 48 hours of receiving the order or upon the date specified in the order if indicated by the physician. Your assessment will be done by a licensed clinician. During the assessment we will be evaluating your specific care needs, your homebound status, and your clinical condition. The clinician will talk to your doctor about the results of the assessment and if you display a need for skilled care and meet Medicare eligibility criteria, a plan of care will be developed in consultation with your physician and you will be admitted for care.

Throughout treatment the Director of Nursing is responsible for the overall coordination of patient care and services, The patient is responsible for informing the agency when unavailable for a visit. Visit schedules are coordinated whenever possible. Patients are notified of significant changes in schedule prior to scheduled visit time, unless an emergency situation prevents it. Patient care will not be interrupted due to staff absences. The Director of Nursing will ensure appropriate staff assignments and coverage. In the event an ordered service cannot be performed, the physician shall be notified and new orders obtained as needed or the patient may be referred to another provider

g. Transfer and Discharge

In general, you will be discharged from the agency once your physician’s orders have been fully carried out, you are stable and the goals we established at the start of care have been met. However, transfer or referral from our service to another care provider, or discharge from our agency may result from several types of situations including, but not limited to, the following:

• You need a different level of care – for example, you are admitted to the hospital
• Situations may develop that affect your welfare – we are no longer the appropriate care providers
• You no longer meet Medicare eligibility criteria – for example, you are no longer homebound
• You fail to meet your responsibilities as a patient – for example, failure to have a face-to-face physician encounter as required by regulations
• You move out of our service area
• You will be given timely advance notice of a transfer to another agency or discharge from our agency, except in case of an emergency. If you should be transferred or discharged to another organization, we will provide the necessary information pertinent to your continued care. When discharge occurs, you will receive instructions for ongoing care or treatment.