Crackdown on Care at Home

It’s a lot harder these days to get Medicare to pay your home care bills.

This was the fastest-growing part of the giant federal health care system. A nurse would visit a diabetic’s home to give her a daily insulin injection. A stroke victim would have visits at his apartment from a speech therapist, and a homemaker aide would help him bathe.

Congress hit the brakes hard in 1997, concerned about soaring costs and widespread reports of industry fraud. The head of one of the biggest home health care organizations went to prison for bilking taxpayers of millions of dollars for services never delivered.

The crackdown by Congress is having another troubling effect: It’s made it much more difficult for many people to get benefits due to a new, much-stricter payment system. In the past, the patient’s doctor and the health care organization decided how long treatment would last, and then billed the government. Under the new rules, the government sets a limit on how much the organization can bill the government for treatments.

A home health care agency budget is now linked to its average annual spending per case. For example, if an agency spent an average of $3,000 a year in the past, and gets 100 cases this year, the total payments from Medicare for the agency will be $3 million. The new rules, which began last year, provide a system for slowing down the growth of spending, but also deliver a powerful incentive to avoid the costly cases, the ones that might run into thousands of dollars a year.

“It’s a terrible situation for seniors; there is a huge crackdown on home care agencies,” said Jamie Court, director of Consumers for Quality Care, a Santa Monica-based advocacy group. His 96-year-old grandmother, who was injured in a car accident and couldn’t lift her arms above her shoulders, had her benefits terminated when the agency declared her condition was stable and didn’t require further visits. Luckily, she is able to pay for the physical therapy and homemaker aides with her own money.

Others without sufficient funds may not be as fortunate. There is a “no-care zone” developing, said Joe Hafkenschiel, president of the California Assn. for Health Services at Home, a trade group.

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For Medicare beneficiaries--people age 65 and over, and the disabled of all ages--who need home care, this is a time to be particularly vigilant, to know all your rights under Medicare and to exercise them with determination.

You qualify for health care at home if a physician certifies that you need skilled care on an intermittent basis. And you must be homebound, unable to get to the doctor’s office on your own. The benefit includes “nursing care, physical therapy, speech language pathology services, home health aide services, durable medical equipment (such as wheelchairs, hospital beds, oxygen and walkers) and supplies,” according to the government guide “Medicare and You.” The services are free, but you pay 20% of the Medicare-approved charges for the equipment. The services must be provided by an agency approved by Medicare.

Under the old system, there were astonishing variations in the use of the program, depending on local doctors and the particular insurance companies handling the processing of claims for the geographic area. Nationally, the average beneficiary using home care--about 10% of the Medicare population in a given year--received 74 visits in a year. But the number was as low as 35 in Oregon and as high as 160 in Louisiana. For reasons unknown, the South was the best place to get home care, with average visits of 121 a year in Alabama, 113 in Tennessee and 130 in Texas. California’s figure was 51, according to a report compiled by the American Assn. of Retired Persons.

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The new system, tied to past spending by an agency, is much more circumscribed. One key tip: If you anticipate a long and difficult recovery, look for an agency with high average spending, greater than the typical $3,000 cost per case. Ask the agency what its average cost per case was last year.

“Sometimes you can use the physician to leverage the home health agency,” said Aileen Harper, head of direct services for the Center for Health Care Rights, a Los Angeles-based Medicare advocacy organization. “You need the strong support of the physician.” Make sure the doctor prepares a detailed treatment plan, with extensive details about the patient’s problems and the kinds of treatment and assistance she needs, and her inability to manage on her own or travel outside the home for treatment, says Harper.

If the home health agency decides to terminate treatments, you are entitled to a written notice of non-coverage. Many firms don’t bother notifying patients, simply telling them that Medicare will no longer pay for their care. That is a violation of Medicare rules, said Harper.

Insist on the written notice, and tell the agency you want to file a Medicare claim even if the home health agency doesn’t think you meet Medicare guidelines.

For questions about Medicare home health care and rules of coverage in California, the firm handling the Medicare claims is Blue Cross of California at (805) 383-2990.

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Question: Can you recommend a sincere, thoughtful insurance person to consult with in regards to long-term-care insurance? I have a 79-year-old mother-in-law who is worried about losing her savings if she is confronted with this problem. As of now, however, she can still manage fairly well. She drives, shops and is able to run errands for herself.

Answer: Most people are unaware that Medicare does not cover costs for custodial nursing care, which can run $40,000 a year or more for a nursing home. The government, under the federal-state program known as Medicaid (MediCal in California), will pay for the nursing home only after you have “spent down” and impoverished yourself. However, long-term-care insurance will pay for such things as home care, an assisted living apartment, or custodial care in a nursing home. The decision on whether to buy this private coverage is a complex personal calculation. The Healthcare and Elder Law Programs Corp., known as HELP, holds classes on issues like long-term-care insurance and MediCal. Check the Web site at https://www.palosverdes.com/helpcorp or call (310) 533-1996.

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Q: I am retired at 63 and was with the same company for more than five years. My wife and I are covered under a group plan that provides the same coverage as when I was employed. (This is COBRA, the Consolidated Omnibus Budget Reconciliation Act, the federal law allowing a worker to continue insurance for 18 months after leaving a job.) What is your understanding (about) extending the coverage?

A: You have additional coverage guarantees under CAL-COBRA, a state law, which says anyone over age 60 with at least five years on the job can keep insurance in force until reaching age 65, when Medicare takes over. Your COBRA coverage ends before you turn 65, but CAL-COBRA will take you the rest of the way. You are responsible for the full premium, both your share and the employer’s share, plus an administrative fee. Before your COBRA benefits expire, tell your former employer that you want to shift to CAL-COBRA coverage.

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Q: I have elderly parents who live in Texas and am concerned how they will be cared for when it is needed. I was interested in the federal law that says that if one spouse enters a nursing home, the other spouse can stay at home and is able to keep some of their financial assets. What federal law is this and where can I obtain more information?

A: The Medicaid spousal protection law provides that the person at home can keep at least $80,000 from the couple’s financial assets, and possibly more, depending on complex income rules. Check with the county bar association where your parents live for the name of an attorney specializing in elder care law. Or contact the local Area Agency on Aging for advice.

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We welcome your suggestions, questions and tips about the fast-changing world of health care. Write to Bob Rosenblatt, Health, Los Angeles Times, Times Mirror Square, Los Angeles, CA 90053. Or e-mail to bob.rosenblatt.latimes.com.