CHARLOTTE, NC: ALS is an affliction of never-ending change and surprise. Frequently the changes are discouraging. However, now and then a surprisingly positive development occurs bringing hope and comfort to ALS victims. One little-known benefit is that Medicare health care allows up to 35 hours a week of combined home healthcare services for ALS victims.
Everyone who is eligible for these services should, at the very least, check into the possibilities of Medicare health care services.
Medicare health care qualifying conditions
In a May 9th article written by Rick Jobus, the author explains that qualifying conditions are outlined in the Medicare Benefit Policy Manual which offers the basic criteria for home health coverage.
Following are the main provisions of the Medicare Home Healthcare services and the qualifications for them:
• Coverage requires a “trigger.”
The patient must have needs that are “medically reasonable and necessary” and “intermittent.” The intermittent definition is needing “care at least once every 60 days and at most once a day for up to three weeks.”
Coverage can include skilled nursing, physical therapy, speech therapy, occupational therapy, home health aides, medical social services, and medical supplies.
• Your physician must order Medicare health care services
Services must be outlined under a written plan of care. Your physician needs to be fully onboard. Some doctors may have been previously unaware of the Medicare home health care benefit, so be prepared with printouts, website addresses, and contact information. Make it easier for your doctor.
Because recertification is required, the doctor’s office workload will increase.
• Recipients must be homebound.
Homebound means he or she must lack the ordinary ability to leave home, without requiring the assistance of an individual or supportive device, and without expanding “considerable and taxing effort.” Leaving the house for healthcare appointments, church services, weekly support group meetings, brief errands, occasional special celebrations, and daily short outings in the neighborhood park, are allowable. You don’t become a prisoner in your home, but the service is for those who need help getting health care.
• Care must be provided by a Medicare-certified home health agency (HHA).
As with the physician, the HHA selection is critical, and the Medicare certification requirement narrows the list. Ignorance of the home health coverage criteria is prevalent in the HHA sector. This often means it is incumbent upon the ALS patient to be persistent and to pursue solutions without giving in to uninformed information.
Further, under Medicare’s Prospective Payment System, payment is made based on a predetermined, fixed amount. Regardless of the actual mix of services and hours provided. Thus, the more care an individual receives, the less profit the agency makes. This leads to some agencies to reduce their weekly assistance or forego the process entirely.
If at first, you don’t succeed, try, try again
The best advice is to keep inquiring with various Medicare-certified HHAs to find out if they have the staff to support a daily, Medicare-reimbursed plan of care. If they balk at the notion, or try to “correct” your regulatory understanding, simply move on until you are successful.
As with everything these days, the process can become time-consuming, tedious and frustrating, but, in the end, persistence should pay off. It could save thousands of dollars in personal healthcare bills while keeping your sanity about the financial eventualities that oftentimes crush ALS patients.
Medicare health care parameters
Since the care plan must undergo recertification every 60 days, it is important that the trigger not be finite.
For example, if someone is receiving treatment for pressure sores, coverage will end when the sores heal.
According to the Medicare Manual:
“Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, to prevent or slow further deterioration of the patient’s condition.”
Restoration potential is not the deciding factor, and there is no time limitation.
Most importantly, if you decide to look into this opportunity, do not let naysayers and skeptics dissuade you. One thing ALS victims should learn from the beginning is that roadblocks to battle the affliction are common.
This process will require you, and your caregivers and support groups, to be persistent. However, by educating yourselves, demanding what is rightfully yours and continually reminding others of the services you should be receiving.
Your determination is the key to success.
Keep all paperwork. File it in a comprehensive manner, either by category or date and keep that file up-to-date. It will be invaluable when someone tells you that something is not available. Then all you need do is pull your corroborating information from your files.
Consider this, tedious as such a project may seem at first, it is an ideal means of staying busy and doing something positive for yourself that can add immensely to your quality of life in the long run.
Whatever you do, put away the white flag and never surrender to ALS. After all, this is information you can “live with.”
About the Author:
Bob Taylor is a veteran writer who has traveled throughout the world. Taylor was an award-winning television producer/reporter/anchor before focusing on writing about international events, people, and cultures around the globe.
Taylor is the founder of The Magellan Travel Club (www.MagellanTravelClub.com)
Editors Note: Support Bob’s GoFundMe to give him a hand up