One of the most vital and often misunderstood parts of Medicare is the home health-care benefit. It offers physical therapy, speech therapy, injections and other vital care for millions of Americans in their own homes.
About 3 million people a year use the benefit, but many more might do so if patients, their families and doctors had a better understanding of what is available.
There may be hundreds of thousands of people newly eligible, for example. Last year, Congress changed the law to cover those with Alzheimer's disease who go to adult day-care centers, but who also have other ailments--such as cancer, diabetes or congestive heart failure--requiring intermittent skilled care at home.
The day-care centers provide physical and mental exercises to preserve the remnants of patients' diminishing memories. But until this year, patients couldn't receive the home-care benefit because they regularly left home.
Traditionally, the Medicare rules said you could leave home only to go to the doctor or to attend religious services. Otherwise "home-bound" has meant just that.
The change is a tremendous boon to Alzheimer's patients and their families, said Judy Riggs, deputy to the vice president for public policy at the Alzheimer's Assn. "This is an issue we worked on very hard for years," she said.
Congress also helped make things easier for doctors, who must certify that patients need home care. Under Medicare's elaborate billing system, with a numbered code for every procedure, there was no formal way to reimburse doctors for the time they spent drawing up the treatment plans for patients at home. Physicians had to squeeze it in with their other work.
Now there are two new official codes (GO 180 for the initial certification and GO 179 for the recertification) to pay the doctors, and this should encourage them to take more time and interest in working with their patients on this benefit.
But there are still arbitrary and confusing restrictions, and it is vital for patients, families and physicians to understand the rules.
For those who qualify, home health care can be generous: It is a free benefit. Unlike the other parts of Medicare, there are no deductible and no co-payments.
But the benefit is limited to people who need skilled, intermittent care. That means the services of a nurse, a therapist (physical, occupational or speech) or other medical professional. And the need must be occasional: Someone who needs round-the-clock care might be eligible to go to a hospital or nursing home, but not to receive the care at home.
Take the hypothetical example of Mrs. A, who has very bad arthritis. Some days her gnarled hands are so painful she can barely button her dress and can't turn the knobs on the stove to prepare meals. She also has high blood pressure that varies erratically and has put her in the hospital twice in the last two years.
If she qualifies for the benefit, a physical therapist can teach Mrs. A some exercises to reduce the pain. An occupational therapist might teach her how to use a device making it easier to manipulate the buttons on her clothing. A nurse may come to the house to monitor her blood pressure and suggest changes in medication.
The doctor offers the key to entering this complex system. He or she must order the home-care benefit, certifying that the patient needs the services. An "episode" of care lasts 60 days. After that, the patient must be certified again by the doctor.
But it is not enough for Mrs. A to have her medical problems. To get the benefit, she must also be homebound. That means it takes a "considerable and taxing" effort for her to leave home, and any trips are infrequent or of short duration.
Because the arthritis is so troubling, it takes Mrs. A. two hours to bathe, dress and get ready to go out. She would qualify.
Although going to the doctor and religious services are allowed, the "reality is that some people "are imprisoned in their own homes," said Jeff Kincheloe, deputy director of government affairs for the National Assn. for Home Care, which represents many of the certified agencies that provide home-care services. "They fear losing their benefits, so they never leave home," he said.
Recently, a man with Lou Gehrig's disease was stripped of his benefits because he was leaving the house on a regular basis to make public appearances to discuss his disease and to encourage other patients. It took the intervention of a congressman to get the benefits restored.
The rules on being homebound are waived for those who attend an accredited adult day-care center. This is a facility licensed by the states and able to provide "psycho-social" services, according to the official government definition. Simply being transported to a senior center isn't sufficient.
The accredited centers offer group activities, counseling, memory-stimulation courses and exercises for the individual suffering from Alzheimer's disease or other dementia.
This helps the patients, who often become agitated and depressed as they get increasingly forgetful. They will be more calm and manageable when they return home. And it allows the caregiver, the spouse or other family member or friend taking care of the patient, to go to work, shop or simply take a few hours off.
A booklet on the home-care benefit is available from the Health Care Financing Administration, which runs Medicare, by calling (800) MEDICARE. Information also is available on the HFCA Web site http://www.hcfa.gov.
Remember that doctors are the gatekeeper for the home-care benefit. Check with the physician treating the Medicare beneficiary.
When a family member is hospitalized, there should be a discussion with the discharge planner, a nurse or social worker who will know about plans of care after the patient goes home. The discharge planner should be familiar with the home-care benefit and have a list of Medicare-certified agencies that manage the home-care benefits.
These agencies send the nurses or therapists to the home and bill Medicare for their services. The agencies also can provide information about the program. Check the local phone book for Medicare-certified home-care agencies or home health agencies.
Local chapters of the Alzheimer's Assn. can offer information about the change in the benefit for those using adult day care. The general information number for the association is (800) 272-3900.The Web site is http://www.alz.org.
Bob Rosenblatt welcomes your questions, suggestions and tips about coping with the changing world of health care. You can contact him by writing Bob Rosenblatt, Health, Los Angeles Times, 202 W. 1st St., Los Angeles, CA 90012, or by e-mailing firstname.lastname@example.org. Health Dollars & Sense runs the second Monday of each month.