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Questions Re:Medicare Coverage for CNA/Nurse Care

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    Questions Re:Medicare Coverage for CNA/Nurse Care

    Hello Everyone,
    I'm a 50-year-old quad living alone and have a few questions regarding Medicare coverage for home health aide/nursing services. The agency I'm currently with provides me with CNA care 4 hours daily and skilled nursing care once every 2 weeks. The skilled nursing care is a prescribed testosterone injection which I started getting a few years ago as my levels were low and I wasn't responding to Androgel or any other treatment for the low testosterone. Prior to my needing these injections I was with a different agency and was having to pay $1500 a month for CNA care (this was half their usual price). The agency did take Medicare assignment but I don't recall why I was ineligible at that time and was required to pay. Once I started getting those injections, Medicare started paying for all my CNA services as well as the nursing care and some physical therapy.

    That HHA went out of business a little over a year ago. They did try to find another agency to take on my care but were having a hard time, all the agencies they called claim they didn't have the manpower to take over my care. I started making calls to agencies myself and ran into the same problem but eventually got picked up by the HHA I'm currently with. Problem is, the service from this agency sucks big-time. At 1st, they had 2 CNA's available, one in the morning and one for the evening. The morning CNA was okay but the p.m. aid was always late, lazy and hardly spoke/understood a word of English. I sent a letter to the supervisor regarding the problems I was having with the CNA but nothing happened. The a.m. CNA had to leave the company after a few months as she got a DWI and a month later got caught driving with a suspended license. Ever since then, the p.m. CNA has been covering my morning care.

    I've been trying to get another agency to take on my care pretty much since I started with the current agency I'm with. Every agency I called said they didn't have the manpower to take on my care. I find that hard to believe as I'm only asking for 2 hours in the morning and 2 hours in the evening (around 7 PM) plus the nursing care and some of these agencies were quite large with plenty of CNA's on staff. Several people have told me these agencies most likely have the staffing but won't take my case because the amount of Medicare reimbursement is so low.

    A few weeks ago I finally found an agency that said they would take on my care but couldn't do it right away as they had just hired several CNA's who are going through orientation. Last week they asked me the hours I wanted and we had agreed they would start service tomorrow, 5/21, at 9 AM. The only other thing they had to do was get the order from my doctor as well as my medical records. Today, however, I got a call from one of the employees at this agency saying they cannot take on my care after all because my level of care wouldn't meet the Medicare "coverage levels". I explained to him that Medicare was paying for my CNA care and nursing care every month and as long as my doctor wrote an order for those same services, why would it be any different for this new company? Apparently, based on the orders they received from the doctor, the nursing supervisor felt Medicare would not reimburse them for my care. I asked him if there was some way to get preapproval from Medicare but he said there wasn't. This gentleman also mentioned the Medicare healthcare Directive(?) that states I'm responsible for any charges should Medicare deny them. I then offered to fax a copy of a Medicare EOB with the Medicare payments for my CNA/nursing care. However, the person I spoke with said he was in finance and couldn't answer all my questions and suggested I call the nursing supervisor back on Friday.

    My question is, since this company has stated they do have the manpower to take on my care, do take Medicare assignment, and do have the proper doctors orders for my care, are they required by Medicare to take on my care?

    Also, the agency I'm currently with never did hire another aid to replace the a.m. CNA that left the company, isn't it a Medicare requirement that they have at least 2 CNA's available to cover a patient should one go out sick for an extended period of time? Aside from the piss poor care, that's the other reason why I want to go with a new agency, if something happens to the current CNA, I'm SOL.

    Is there anyone on the list that's getting CNA care covered by Medicare and if so how much care are you getting and how did you become eligible?

    Any info/advice y'all can provide is greatly appreciated, thanks!
    Dan G. in CT

    I am just curious about how you ever got Medicare to pay for non-skilled care at all. They certainly will not pay for things such as assistance with ADLs, transfers, homemaking, ROM, bathing, etc. in my area, and we were turned down for even skilled care (catheterization, bowel care, etc.) after only a couple visits more than once for my mother, and have never been able to get that for my clients in Southern CA.

    There certainly is no regulation or law that requires a Medicare certified HHA to take any case they don't want to take...they get to pick and choose.

    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.


      You bring up an interesting point... for people who need an infusion/injection at regular intervals and are considered "home bound", can they get Home Health benefits indefinitely?

      I agree with KLD. It is very atypical to be provided 4 hours a day CNA care through home health services paid by Medicare for years for "maintenance care". Usually home health services are only paid if you have a new/acute medical issue that requires care/intervention, and then once you are back to your baseline.... they cut it off.

      But it sounds like your home health services only started getting paid by Medicare when you started getting the injection, and that the CNA visits were not covered before. KLD might know better then me.... but is this injection need enough to get you qualified long term for home health? Alternatively, they could have you go to a clinic every two weeks, or to just get the injection alone at home, without the other services.

      It is true that when my Mom was on chemo, she received home health services for the entire time of her illness.... but it was only 1 nursing visit a week for 1-2 hours, and a few weeks of PT only after a hospitalization. The nurse needed to come to clean her PORT (an intravenous line), draw blood for lab tests, and sometimes disconnect the chemo and sometimes give a treatment. And I felt we were lucky to get that.

      My gut feeling is that you are very lucky to be getting CNA services at all, and that you may need to stick with what you have or start paying out of pocket again for a better place. But I do sympathize... it can be very hard to get good help at home.

      I find that if you live near a bigger city where there is a teaching hospital, sometimes they have Home Health companies that are based at the teaching hospital and/or work closely with that hospital, and those companies are more willing to work with Medicare patients.

      Medicare is closely scrutinizing Home Health claims now, as there has been much fraud in the past and Medicare is trying to cut costs. I can understand why Home Health companies are more concerned.


        Thanks for your replies. Yes, I do consider myself extremely lucky to be getting my HHA services covered as they are. I believe Medicare calls it a "home health care episode" when a person becomes eligible for HHA coverage, in-home PT, etc. because they need ongoing skilled nursing care. I found the info below at the following Medicare advocacy URL


        Home health claims are suitable for Medicare coverage, and appeal if they have been denied, if they meet the following criteria:

        A physician has signed or will sign a care plan.

        The patient is homebound. This criterion is met if leaving home requires a considerable and taxing effort which may be shown by the patient needing personal assistance, or the help of a wheelchair or crutches, etc. Occasional but infrequent "walks around the block" are allowable. Attendance at an adult day care center or religious services is not an automatic bar to meeting the homebound requirement.

        *** The patient needs skilled nursing care on an intermittent basis (from as much as every day for recurring periods of 21 days – if there is a predictable end to the need for daily care – to as little as once every 60 days) or physical or speech therapy.

        The care must be provided by, or under arrangements with, a Medicare-certified provider.

        Coverable Home Health Services

        If the triggering conditions above are met, the beneficiary is entitled to Medicare coverage for home health services. There is no coinsurance or deductible. Home health services include:

        Part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse;

        Physical, occupational, or speech therapy;

        Medical social services under the directions of a physician and;

        To the extent permitted in regulations, part-time or intermittent services of a home health aide.
        Dan G. in CT


          I think this is a grey area, regardless of your posting. I have never heard of someone getting CNA care forever paid for by Medicare for your reason. When you spoke with the new Home Health company who declined your case, did they point specifically to what they were worried about? I would call the nursing supervisor back to see what she says. Let us know.


            In this area as soon as skilled nursing care is not needed, non-professional services are cut. Even skilled care is limited. If it is not an upfront temporary service only needed a few times a person is only provided skilled care if there is someone who can be trained to take over for the long term.
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