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Federal Changes in Home Care Coverage

In the past decade and a half, significant legislative changes have occurred that directly affect those who require both medical and non medical in home care for the elderly

In 1997, the federal balanced budget act cut payments to medical providers for in home health services for Medicare.  This resulted in a decrease of the elderly and disabled who received long term in home care services.  This caused agencies to be much more discerning in evaluating the medical needs of at home patients.  However in 1999 and 2000 some of these payments to for health care services have increased, allowing agencies and medical providers to provide more in home care for the elderly who need in home nursing services. 

According to the government’s Medicare website, the current guidelines for eligibility for in home health care are:

  • Home health services must be prescribed by the patient’s physician and be submitted with a care plan.
  • The patient must need intermittent or short-term skilled nursing care, physical therapy, speech language therapy, or occupational therapy.
  • The home health services provider must be a Medicare-certified.
  • And the patient must be homebound, meaning that they are unable to leave the home for treatments, or it is significantly difficult for the patient to leave the home to receive the necessary treatments.

Medicare will only cover certain types of in home care for the elderly or disabled.  The types of in home care covered by Medicare are:

  • Part-time skilled nurse home health services that must be provided by a registered or a licensed practical nurse.
  • Part-time home health services provided by a nurse’s aide for help with activities of daily living such as bathing, dressing, or other hygiene and grooming activities, and only if the elderly patient is also receiving skilled nursing care or therapy treatments.
  • In home therapy treatments such as physical therapy, speech-language therapy, and occupational therapy for as medically necessary per a physician’s orders.
  • Medical social services such as counseling to assist in coping with an illness or injury and assistance in finding additional community resources.

Currently, Medicare will not pay for around the clock non-medical home care for the elderly, meal preparation service, homemaker services, or health aid services if medical services are not also being provided.

Due to the current coverage restrictions of the Medicare program, part of The Patient Protection and Affordable Care Act, the healthcare reform bill that was passed in March of 2010, includes an act called the Community Living Assistance Services and Supports Act otherwise known as CLASS Act.  The CLASS Act will make in home care for the elderly and disabled available to many more patients that will need those in home care services in the next decade. 

This is a voluntary insurance program that provides a cash benefit for those who require long term care of any kind.  The insurance can be provided through an employer or purchased independently by individuals.  The CLASS Act portion of the healthcare reform bill will not begin enrollment until after October 1, 2012.  The current stated requirements are that the enrolled member must be currently working and not living in a nursing home, but will not exclude anyone including those with preexisting disabilities.  To receive benefits the beneficiary will have to be working for four out five years that they paid into the plan.

Services that will be covered by the CLASS Act will provide coverage for the following conditions not currently covered by Medicare.

  • Functional impairment or disability expected to last beyond 90 days
  • Difficulty completing two to three activities of daily living, such as eating, bathing, dressing, using the toilet, getting out of bed or a chair, or caring for incontinence.
  • Cognitive impairment such as Alzheimer’s disease or dementia
  • All other conditions currently not covered by the Medicare system, but only covered by Medicaid for the medically necessary indigent

The expected average benefit will be $75 per day.  Since the average nursing home cost is over $200 per day this program will make it easier for families to pay for anticipated in home care costs or to supplement existing private long-term care insurance.  Please contact your local agency.