Seniors Often Must Fight for Medicare Home Health Benefits

Medicare is mandated to cover your home health benefits with no limit on the time you are covered. Unfortunately, few Medicare beneficiaries get the level of service they are entitled to and many find their services cut off prematurely. Getting these benefits can be critically important. Medicare home health care benefits can mean the difference between being able to stay at home with a difficult medical problem or ending up in the hospital or a nursing home.

As a Medicare recipient, you are entitled to full home health benefits if you meet the following requirements:

You must be confined to your home – meaning that leaving it to receive services would be a "considerable and taxing effort."
Your doctor must have ordered home health services for you.
At least some element of the services must be skilled – skilled nursing care, physical therapy, or speech therapy.
You must receive the services from a certified home health agency.
Requiring an element of skilled care also will entitle you to Medicare coverage of social services, home health aide services, and the necessary medical supplies and equipment. You won't have to pay anything for the home health benefits, but you will have to pay 20 percent of the supplies and equipment.

Under the law, you are entitled to 35 hours of service a week, but few Medicare beneficiaries who meet the home health care criteria actually get this level of service. If your services are terminated prematurely, you will need to appeal. If you have to appeal, the good news is that most people win their cases. In fact, 81 percent are successful on appeal to an administrative law judge.

If you can you should continue to pay privately for the care during the process. Remember – the issue you are appealing is not the termination of service, but the denial of Medicare payment for the service.

In order to mount a successful campaign to get your services back, you should:

Ask your home health agency to explain the cutback and write the information down.
Ask your physician to call the agency urging them not to cut back the services and, then have the physician send a letter detailing the level of care you need.
Consult with a Medicare assistance agency or your attorney to determine the likelihood of a successful appeal.
If you decide to appeal, do so immediately and make sure you make arrangements to pay privately pending the result of the appeal.

Source: Elderlawanswers.com, 7/16/07

Should you sign a Nursing Home Admission Agreement?

Admitting a loved one to a nursing home can be very stressful. In addition to dealing with a sick family member and managing all the details involved with the move, you must decide whether to sign all the papers the nursing home is giving you. Nursing home admission agreements can be complicated and confusing, so what do you do?

It is important not to rush, but rather to read. Read the agreement carefully because it could contain illegal or misleading provisions. If possible, try not to sign the agreement until after the resident has moved into the facility. Once a resident has moved in, you will have much more leverage. But even if you have to sign the agreement before the resident moves in, you should still request that the nursing home delete any illegal or unfair terms.

Two items commonly found in these agreements that you need to pay close attention to are a requirement that you be liable for the resident's expenses and a binding arbitration agreement.

Responsible party

A nursing home may try to get you to sign the agreement as the "responsible party." It is very important that you do not agree to this. Nursing homes are prohibited from requiring third parties to guarantee payment of nursing home bills, but many try to get family members to voluntarily agree to pay the bills.

If possible, the resident should sign the agreement him- or herself. If the resident is incapacitated, you may sign the agreement, but be clear you are signing as the resident's agent. Signing the agreement as a responsible party may obligate you to pay the nursing home if the nursing resident is unable to. Look over the agreement for the term "responsible party," "guarantor," "financial agent," or anything similar. Before signing, cross out any terms that indicate you will be responsible for payment and clearly indicate that you are only agreeing to use the resident's income and resources to pay.

Arbitration provision

Many nursing home admission agreements contain a provision stating that all disputes regarding the resident's care will be decided through arbitration. An arbitration provision is not illegal, but by signing it, you are giving up your right to go to court to resolve a dispute with the facility. The nursing home cannot require you to sign an arbitration provision, and you should cross out the arbitration language before signing.

Other provisions

The following are some other provisions to look out for in a nursing home admission agreement.

Private pay requirement. It is illegal for the nursing home to require a Medicare or Medicaid recipient to pay the private rate for a period of time. The nursing home also cannot require a resident to affirm that he or she is not eligible for Medicare or Medicaid.
Eviction procedures. It is illegal for the nursing home to authorize eviction for any reason other than the following: the nursing home cannot meet the resident's needs, the resident's heath has improved, the resident's presence is endangering other residents, the resident has not paid, or the nursing home is ceasing operations.
Waiver of rights. Any provision that waives the nursing home's liability for lost or stolen personal items is illegal. It is also illegal for the nursing home to waive liability for the resident's health.

A certified elder law attorney can clarify all of your options.

Source: www.elderlawanswers.com