Medicare FAQs, Tips and Nasty Surprises – Updated

Home Health Care

What is the most important question to ask when you are discharged from a hospital?

“Is your agency certified by Medicare?”

Medicare patients are often discharged from a hospital and need home health care to complete their recovery. However, Medicare won’t pay for it unless the care is provided by a certified agency. But, only half of all home health care agencies are certified.

Don’t automatically assume that an agency is certified by Medicare, even if your doctor recommends it. ALWAYS ask the agency. If you have to pay for their services out of your own pocket, recovery care at home can be very expensive — often thousands of dollars. Remember: If you are discharged from a hospital and need home health care while you recover, ask if the agency is Medicare-certified BEFORE you hire them.

Tip: Many excellent home health care agencies are not certified by Medicare. But, it isn’t because they aren’t good enough. Instead, their nursing care plans only provide services that aren’t paid for by Medicare, but which their clients need in order to remain in their own homes. Examples include grocery shopping, meal preparation, using the telephone, laundry, light housekeeping, bill paying and managing medications.

Will Medicare pay for home health care if you live in an assisted living facility?

Even though Medicare benefits don’t cover your assisted living expenses, they will pay for home health care you need to recover after a stay in a hospital, and for therapy if prescribed by your doctor. In other words, Medicare benefits cover the home health care you need to recover regardless of whether you live in an assisted living facility, a house, your child’s home, an apartment or an independent living facility.

Skilled Nursing Facilities / Nursing Homes — What if you don’t like the one where you are sent to recover?

If you or your family moves you into another skilled nursing facility, Medicare won’t cover you there, even if the second one offers you a better chance for full recovery. Instead, you’ll have to pay the entire cost of your stay in the second facility out of your own pocket.

Tip: Your loved one doesn’t have to go to the skilled nursing facility where their hospital wants to send them.

Nasty Surprise

If a hospital discharges you and sends you to a skilled nursing facility for recovery, you have to pay the cost of transportation out of your own pocket, even if an ambulance is used. Medicare only pays for transportation in cases of emergency; most facility transfers don’t count as emergencies.

UPDATE – Nasty Surprise #2

Seniors are often discharged from the hospital before they’ve recovered enough to be sent home. Instead, they’re sent to Skilled Nursing Facilities (specialized nursing homes) to recover. But, does Medicare pay for their nursing home care?

NO, unless a restrictive rule is followed:

You must have been admitted to the hospital
as an in-patient for 3 consecutive days.

In today’s confusing world of healthcare, hospitals frequently admit some seniors for observation instead of being in-patients. Under the observation status, seniors are entitled to the same healthcare as they would have received had they been admitted as in-patients, but the hospital protects itself from some financial penalties. And, the days spent in observation do NOT count toward the 3-consecutive-day requirement.

So what?

If you don’t meet the 3-day requirement, and require skilled nursing care to recover, Medicare will NOT pay for your skilled nursing home stay. And, because Medicare won’t cover your stay, your Medicare Supplement policy won’t either.

In other words, you will have to pay hundreds of dollars out of your own pocket for EACH DAY you spend in skilled nursing care.

Is there a solution to this “gotcha?” Yes … sort of.

Beginning August 6, 2016, hospitals are required to notify “observation” patients in writing that they may incur huge out-of-pocket costs if they stay more than 24 hours without being formally admitted as in-patients. Patients can then consult their doctors and ask to be reclassified as in-patients.

But, will this solve the problem. I’m doubtful.

If you’ve ever been hospitalized, you know that you are asked to sign forms virtually every day. Will this one be adequately explained to you? Will you be cognizant enough to understand what it’s for — to remember to talk with your doctor about being reclassified?

To me, the new law sounds like the best of intentions that have every possibility of not working like it should. Bottom line, it adds one more layer of complexity to an already complex healthcare situation.

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