Due to its elderly population, South Florida is the most competitive market in the country for Medicare plans.
Home healthcare is a “a necessary benefit” of Medicare, said Kathleen Sarmiento, SHINE (Servicing Health Insurance Needs of Elders) Liaison at the Alliance for Aging.
“Medicare pays home health to avoid hospital remittance and to make sure you are healthy,” Sarmiento said.
The goal of home healthcare is to provide treatment for an illness or injury, according to Medicare. But, it is often a high bar to clear to get approval for home healthcare, said Phil Moeller, author and writer about Medicare and Social Security for the “PBS News Hour.”
People are eligible for Medicare coverage of home healthcare under certain conditions, which include: being certified homebound, needing intermittent skilled nursing services or physical or occupational therapy, having a care plan from a doctor, and receiving care from a Medicare-certified home health agency.
“It can be hard to find a really good home health agency because agencies have a hard time finding qualified people because the positions don’t pay a lot,” Moeller said.
Another hurdle can be getting a chosen home health agency to choose you back. Since an agency has a choice whether to care for someone, agencies often cherry pick the people that are the most financially advantageous to them, which sometimes leaves a patient without an agency, Moeller said.
Moeller suggests that people don’t assume a home health agency will provide coverage. He encourages people to do their homework and check out an agency to see if they will accept you.
If there isn’t an agency that will accept you, contact the local office of the State Health Insurance Program (SHIP) for assistance.
Once care from a Medicare-certified home health agency is received, some people often find it limiting that long-term healthcare is not covered, Sarmiento said.
Medicare provides for home health coverage for fewer than eight hours daily.
“In a perfect world, there would be enough money for home health agencies to come as often as needed and provide daily care, including meal preparation, bathing and companionship,” Sarmiento said.
“Family members become unofficial unpaid caregivers,” Sarmiento said. “There [is a generation of] people who are taking care of their parents and their children, which are mostly baby boomers. It is the sandwich generation.”
Sarmiento encourages those seeking to apply for Medicare to contact the Alliance for Aging, Miami-Dade County’s elder care agency.
If ordered by a doctor, services to help a patient with social and emotional concerns related to an illness will also be covered. Medicare also pays in full for certain medical supplies, such as wound dressings and catheters, when provided by a Medicare-certified home health agency.
Medicare pays 80 percent for some medical equipment, such as a wheelchair or walker. But, traditional Medicare excludes other services from coverage, including: prescription drugs (Plan D), meal delivery, light housekeeping and laundry.
Medicare Advantage plans can often pick up the slack. Medicare Advantage is a health plan that provides benefits through private insurance companies, which contract with the Medicare program. These plans usually offer low or zero premiums and may provide benefits beyond Medicare. Some plans offer assistance with daily living services, dental, vision, prescription drug, and discounts for fitness gyms.
Patients should review benefits of the Medicare Advantage plans to find out if their needs will be met long term, said Casey Schwarz, senior counsel, education & federal policy, for the Medicare Rights Center. She encourages people to find out what drugs are covered and the doctors participating in the Medicare Advantage plan they choose.
“For some patients, being able to choose a doctor is a high priority,” Schwartz said.
Next year, Medicare Advantage will also cover non-medical expenses, such as a grab bar in the shower and nutritional meals, Moeller said.
“Medicare Advantage can provide greater coverage of nontraditional items that will improve their health and reduce long-term care because people are healthier,” Moeller said.
But, people must shop around to reap the benefits, Moeller said.
“[Shopping for] Medicare plans can be traumatic and complicated so people just stick with a plan and don’t change,” Moeller said. “If people with Medicare shopped around instead of sticking with a plan, it could be better financially and give them more for what they need at less cost.”
Alliance for Aging: Miami-Dade County’s elder care agency.
SHINE (Serving Health Insurance Needs of Elders)