Home Health Visits

Perhaps you saw a recent article by reporter Barbara Martinez in the Wall Street Journal concerning the Medicare Home Health benefit. The article suggests that home health agencies make therapy visits to Medicare beneficiaries not strictly according to their medical condition, but also according to Medicare reimbursement rules. It says that where Medicare payment rules have a “tipping point,” that is, a certain set number of therapy visits where, if the agency exceeds this number of visits, it gets a higher reimbursement amount, agencies tend to go ahead and give those extra visits. And, of course, claim the extra reimbursement. The Home Health Agencies say there are other factors driving this.

Strictly from the beneficiaries’ point of view, this probably tends to incentivize the agencies to have therapists – whether occupational or physical – make more visits to you than they otherwise might. And to the extent that these visits truly improve your condition, this would be good for you, because, as laid out in the section of Managing Your Medicare on home health (see pages 133-137), you don’t have to pay anything for home health visits. But what the article also indicates, although not as explicitly, is that changes in Medicare reimbursement rules have also caused a decrease in other types of visits, both skilled nursing visits and medical social services visits. And this would result in your getting fewer of these kinds of visits than you might otherwise receive, which might not be the best thing for you.

Perhaps the upshot of this is to remind beneficiaries and their caregivers that they have the right to get an independent review of the cut-off of home health visits. This is fully explained the appeals chapter, on page 199. So if you think your visits are being cut off before they should be, appeal at once to the Quality Improvement Organization in your state.

Medigap Changes Coming in June of 2010

I had a call from a senior center from a gentleman who would be getting Medicare in June. We discussed various options, and I also went to look up available Medigap policies on his state's Commissioner of Insurance website. And, sure enough, they had only the Medigap policies available through May of 2010. In June, the structure of Medigap policies changes. Table 15 on page 141 of the book shows the policies currently available, while the policies that go into effect in June of 2010 are explained on page 157. And there is a table on the CD, "Medigap Standard Policies Worksheet for June, 2010 and Forward," to help you with the new ones.

The rule is that if you sign up for a policy through May, you get to choose from the policies in effect through then, even if you don't actually get covered until later, say July, when you become 65. If you sign up for one in June or later, you have to get one of the new policies. The problem is that not all Insurance Commissioners' websites have the new policy information available yet, and my experience is that they may not even have it beginning in June. For example, Georgia's doesn't say anything about the new policies, Texas's and Kansas's at least tell you the new policies are coming, and some, such as Connecticut's, actually give you the new rates. So during this transitional period you may wish to call your SHINE or your Insurance Commissioner's office to see if you can get the very latest information.

What is Medicare?

• A social insurance system receive by those aged 65 or over
• Designed to provide financial assistance for those at risk for requiring a moderate to high level of medical care
• Also cover disabled persons under the age of 65 and people of any age with end-stage renal disease

There are many different programs within Medicare, within which there are subprograms to fit one's precise needs. It can get a little confusing if you're not familiar with Medicare!

Stay tuned for more updates, answers to common questions and more information from a Medicare insider!