Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.
I learned the hard way: The greatest and the most predictable danger for older people is falling. Too often, a broken hip can lead to a deep and irreversible decline in one’s health or well-being if you don’t get the best of help quickly. For me, I was laid temporarily low by a mild concussion.
Fortunately, for those of us who are eligible, Medicare and Medicaid have made some advances in fashioning benefits that will keep patients at home to mend instead of keeping them in a hospital which can be dirty, dangerous and expensive, or sending them to a nursing home, where the pampering, diapering and surroundings can be even more debilitating.
I hope this is not too basic, but in case you’re a caregiver or a potential patient and you don’t know, or haven’t read the 2010 “Medicare and You” manual, under the Medicare law, after a hospitalization of at least three days – say, for an accident, a stroke or for a broken or surgically mended hip – a patient is entitled to up to 20 days of rehabilitation and therapy in a skilled nursing facility at no cost. (After 20 days the cost is more than $133 a day). The skilled nursing facility, I should add, is not a nursing home. But nurses and therapists are available to help you bathe and dress until you’re able to do so for yourself.
A very important (and inexpensive) alternative, when leaving the hospital or the nursing facility or if you simply need medical help getting over a wound or illness is home health care, which Medicare covers and will cost you nothing. This is one of the best Medicare benefits, although too few beneficiaries or caregivers know about it.
I learned something about Medicare Home Health Care just a few days ago after I took a serious fall from the steep brick steps leading into my home, which left me with bruises, a minor concussion and further impairment of my right arm and leg, which had been weakened by a stroke six years ago. For those of you who are wondering, even six years into a stroke, therapy can help.
That meant I needed trained professionals to look after my recovery from the concussion and to provide physical therapy to get me back on my feet. All it took to get part-time home health care was a prescription from a savvy emergency room physician who wrote in his Rx that the care was “medically necessary.”
As the manual says, “a doctor must order it and a Medicare-certified home health agency must provide it.” That’s especially important for in past years, Medicare cracked down on fly-by-night agencies who charged but didn’t deliver adequate care.
The hospital may recommend an agency, but you should use one that is recognized. In my area, the best is the Johns Hopkins Home Health group.
The home health services may include medical social services, making sure you have help in the home, and part-time or intermittent home health aide services such as checking on a bandage or an IV, administering drugs or simply keeping track of your vital signs and the healing of a wound or a surgical site. The manual says that “you must be homebound” to receive such services, but that means you can leave home to visit a doctor, go to religious services or even go to adult day care.
In my case, the nurse, Anne Bilderback, came to the house twice a week to check my progress in getting over that concussion which left me weakened and occasionally dizzy. Another fall in the house could have been disastrous. She checked to make sure there were no side effects and lectured me on the need to drink fluids and keep my feet up to minimize swelling. And twice a week a physical therapist came to the house and spent an hour with me helping me to walk, exercise my leg and even get up and down the steps from which I fell.
Medicare will not provide 24-hour nursing care nor will it provide meals or help with bathing and dressing unless these services are necessary for your plan of care. In short, if bathing, dressing and meal taking are the only problems you have, they won’t be covered by Medicare. And if oxygen or a wheelchair or other durable medical equipment is required, Medicare will pay 80 percent of the cost.
One more important thing about home health care. Medicare generally pays for up to nine weeks of visits and as much as 35 hours of care per week, although that may vary depending on the reasons for the care. My problem required much less than nine weeks. But Anne told me that a private, for profit company, for which she worked would urge her to discharge patients too soon in order to save money.
If you have a Medicare Advantage HMO or PPO, it is supposed to offer you the same benefits that original Medicare offers. But some private insurance companies use only those health care agencies with which they have special business relationships - such as getting kickbacks. This, plus the fact that some agencies billed Medicare for patients they did not see, were among of the reasons Medicare cut its support for home health care a few years back.
So be careful about which company you choose; check with a doctor or someone you know. And if you think you’ve been discharged too soon, you have the right to make a quick appeal.
See the Medicare website where you or a care giver may find and compare Medicare certified private (proprietary) and public non-profit home health care agencies. Or if you enter home health care in the search box, you may download or read all 35 pages of the manual on the subject, which may be more than you want or need to know.
After discharge from home health care, you may continue physical or occupational, or speech therapy with a doctor’s prescription. If you go to a private therapist, you may run into a cap on the number of visits which was imposed by Congress a few years ago, although there are exceptions for some conditions.
But there are no caps if the therapy takes place in a hospital. In any case, Medicare pays 80 percent of the cost of therapy; you or your supplemental policy pays the rest.
Finally, most of the benefits I’ve described are provided by Part B of Medicare which, as most of you know, pays most of the cost of outpatient services – doctor visits, labs, x-rays. If you don’t have Part B, it’s open for general enrollment until March 31.
This is one of two pieces on Home Health Care. Next time: Medicare and the blight of Depression.Questions: Write to firstname.lastname@example.org.