Such coverage includes the following: doctor services; nursing care; medical equipment (such as wheelchair or walkers); medical supplies (such as bandages and catheters); drugs for symptom control or pain relief (may need to pay a small copayment); hospice care and homemaker services; physical and occupational therapy; speech-language pathology services; special workers services; dietary counseling; grief and loss counseling; short-term inpatient care (for pain and symptom management); short-term respite care (may need to pay a small copayment); and any other Medicare-covered services needed to manage pain and other symptoms.
However, Medicare will not cover the following: treatment aimed at caring for terminal illness; prescription drugs to care for the illness rather than symptoms control or pain relief; care from any hospice provider not set up by the team; room and board; and emergency room, inpatient facility care or ambulance transportation with Medicare covering hospice.
Part B covers payment for physicians’ services; home health care; services and supplies, including drugs and biologicals that cannot be self-administered; diagnostic X-ray tests, laboratory tests and other tests; X-ray therapy, radium therapy and radioactive isotope therapy; surgical dressings, splints, casts and other devices for fractures and dislocations; durable medical equipment (DME); braces, trusses, artificial limbs and eyes; ambulance services; outpatient and ambulatory surgical services; outpatient hospital services; physical therapy services; occupational therapy services; outpatient speech therapy; comprehensive outpatient rehabilitation facility services; rural health ethnic services; institutional and home dialysis services; qualified psychologist services; therapeutic shoes for patients with severe diabetic foot disease; influenza, pneumococcal and hepatitis B vaccine; mammography screening; Pap smear screening, breast exams and pelvic exams, and; colorectal cancer screening, diabetes training tests, bone mass measurements and prostate cancer screening;
The following are not covered by Part B: custodial care; personal comfort items and services; prescription drugs not administered by doctors; routine physical checkups; eyeglasses or contact lenses in most cases; eye examination for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses; hemorrhoids and examinations; immunizations except for influenza, pneumococcal and hepatitis B vaccine; cosmetic surgery; dental services, and; routine foot care.
Still, CMS issued regulations to cut home health care payments by nearly 8 percent in both 2011 and 2012 and nearly $40 billion again under Obamacare, also known as the Patient Protection and Affordable Care Act (PPACA) through 2019, translating into cuts to home health agencies and hospice care facilities, driving many of both categories of care out of business, particularly in rural health, and impacting seniors, especially the terminally ill.
Additionally, CMS released regulations to place a cap on payments for outpatient therapy services under Medicare Part B around 2010, reign in the number of unused drugs in long-term care facilities by asking Medicare Part D plan sponsors to contract with network pharmacies serving long-term care to dispense brand productions in 14 days or fewer increments and to eliminate Part D cost-sharing for full benefit, dually-eligible people receiving home and community-based services (HCBS).
With respect to transportation for seniors in home health, short-term and long-term care, Medicare covers ambulance services but not non-emergency medical transportation, except under Medicare Part C/Advantage programs, which restricts service to bedridden patients.
Nonetheless, aside from covering nursing home care, Medicaid provides both emergency and non-emergency transportation, from a nursing home or a senior’s home for medical appointments, empowering low-income disabled seniors.
Medicaid is providing more and more funding for HCBS, including a number of waivers to assist states serving nursing-home eligible patients for a wide variety of non-medical transit reasons such as grocery shopping. Still, income guidelines would disqualify hundreds of thousands of seniors who are too poor to pay for medical care overall.
The most affected by restrictions on Medicare and Medicaid funding for transit are severely ill seniors stricken with such illnesses as leukemia and multiple sclerosis. These patients need to visit dialysis treatment centers for kidney dysfunction and cancer therapy facilities.
“It is a complete mess,” Curler said of Medicare, stating that her prices are below-market to make her services affordable for seniors and their families. “I help women aged 35 to 55 get a plan in place. I get to [the] cases earlier and brainstorm with people [how to put together a medical care plan].”
Because of her own experiences in providing and coordinating care for her parents, she said she does not favor placing seriously ill seniors in nursing homes if there are more viable alternatives. In one particular legal case involving another attorney, the senior in the family in question already suffered greatly under medical care in a nursing home by the time the relatives understood what was needed and organized the resources for appropriate care.
“I don’t believe there is quality [of life or care] in nursing homes,” Curler said. “[I] don’t want to go nursing home myself [so I know that my] clients don’t want to [either]. I know what I don’t want. I get gerontology care, do assessments of [the patients] and [provide them with a] special plan. What is needed? What is [the best] environment? What does it [mean to] be in a home?
“It is a business plan [and] it is client-driven. [It does] not [involve a] nursing home. [The] only time [that we must discuss care in a] nursing home [is] for those [with] special dementia and other issues.”
She said that she speaks with seniors and their relatives and caregivers and makes them more knowledgeable about the different forms of care, government benefits and other resources than she was when she was providing assistance to her parents.
This article was originally published March 10, 2014 on the website of PharmPsych.com, one of seven websites that comprise The Pharm Psych Network, a medical communications and education company.