Health Care Information

• Assisted Living Facilities
• Durable Medical Equipment Guidelines
• Home Health Care Medicare Guidelines
• Homemaker and Companion Services (no-medical)
• Skilled Nursing Facility Admission Requirements
• Transportation Services Guidelines

Assisted Living Facilities

Assisted Living Facilities provide independent living in a home-like setting while also providing assistance in personal care.  Facilities are licensed by the Agency for Health Care Administration (AHCA) to provide services under a "Standard" license for routine personal care, or a "Specialty" license for more specific services.

• Standard License:  Trained Personnel assist residents with activities of daily living (ADLs).  These activities include ambulation, bathing, dressing, grooming, toileting, and eating.  Personal care does not include nursing, dental, or mental health services.  In addition to ADL assistance, ALF's provide medication supervision, prepared meals and snacks, transportation to medical appointments, and activities designed to promote social and intellectual interaction.

• Limited Mental Health (LMH):  An ALF providing LMH services consults with the resident and the resident's mental health case manager to develop and implement a community living support plan.

• Limited Nursing Services (LNS):  An ALF with a LNS license offers specific nursing services, which may include performing passive range of motion exercises, applying ice caps, collars and heat, applying and replacing routine dressings, care for stage 2 pressure sores, care of casts, braces, and splints, performing ear and eye irrigations, supervision and care of catheter and colostomy bags.  Nursing services required shall not be complex enough to require 24-hour nursing supervision.

• Extended Congregate Care (ECC):  An ALF with an ECC license may provide LNS as well as additional nursing services, administration of medication and treatment pursuant to a physicians order, total assistance with personal care, supervision of residents with dementia and cognitive impairments.  Admission requirements are that the individual must be free of communicable disease, able to transfer (with assistance if necessary), not bedridden, not a danger to self or others, not have stage 3 or 4 bed sores, not require oral suctioning tube feeding, monitoring or blood gasses, skilled rehabilitative services, treatment of a surgical incision, or require 24-hour nursing care.

Medicare does not cover the costs of living at an Assisted Living Facility.  Many Assisted Living Facilities (ALF), require an individual to be:

• Independently mobile - able to perform activities without another person present, with or without adaptive equipment.
• Able to transfer independently on and off the toilet, to and from a chair, bed, etc., on a consistent basis throughout a 24-hour day as needed.
• Independent in feeding.
• Able to dress and undress themselves, only requiring set up for daily dressing/undressing and minimal verbal direction by another person.
• Independent in toileting with appropriate hygiene.
• Independent or require minimal assistance with hair washing, showering and tub bathing, combing hair, shaving, and oral hygiene, including the washing of hands, face and private areas.
• Oriented to person and place, and able to follow immediate two-step direction.

In addition to the above, some Assisted Living Facilities also provide:

• Medication management (administered and/or supervised)
• Diabetic Management (assistance with glucose monitoring, insulin administration, 24-hour snacks)
• Oxygen monitoring
• Nebulizer treatments
• Incontinence care
• Foley care
• Osotmy care
• ADL assistance (bathing, dressing, grooming, etc.,)
• Wound care
• Separate/secured Alzheimer's & dementia care

Durable Medical Equipment Guidelines  

Durable Medical Equipment (DME) is equipment which meets all of the following requirements: Can withstand repeated use, is primarily and customarily  used to serve a medical purpose, is generally not useful to a person in the absence of an illness or injury and is appropriate for use in the home.

Often a physician will prescribe special equipment for use by a beneficiary in his/her home. The equipment may provide therapeutic benefits or enable the beneficiary to perform certain tasks that he/she is unable to undertake due to certain medical conditions and/or illness.  DME includes, but is not limited to:

• Diabetic supplies
• Canes, crutches, walkers
• Commode chairs
• Home oxygen equipment
• Hospital beds
• Power operated vehicles
• Seat lift mechanisms
• Traction equipment
• Wheelchairs

Prosthetic items replace all or part of the function of an internal body organ.  Orthotic items are used for correction or prevention of physical deformities.

• Artificial limbs and eyes
• Breast prosthesis
• Corrective lenses after cataract surgery diabetic shoes
• Leg, arm, and neck braces

The cost for supplies under Medicare are covered under Medicare Part B. A physician will issue a Certificate of Medical Necessity (CMN) and the supplier will coordinate with the doctor to see that all of the necessary information is submitted to Medicare.  

A change in prescription and/or a change in condition requires that an updated certificate be completed and submitted. The following items require a CMN:

• Air-fluidized beds
• Continuous positive airway pressure devices (CPAP)
• Hospital beds
• External infusion pumps
• Lymphedema pumps/pneumatic compression devices
• Osteogenesis stimulators
• Oxygen
• Parenteral and enteral nutrition
• Power operated vehicles or scooters
• Seat lift mechanisms
• Transcutaneous electronic nerve stimulators (TENS)
• Wheelchairs

Medicare approves some DME items for purchase while others must be rented.  Rented items may be kept for as long as it is medically necessary.  Medicare requires the supplier to provide a "purchase option" after the item has been rented for nine consecutive months.  If the purchase option is exercised, Medicare will make a total of 13 rental payments.  You then own the equipment and Medicare will pay for necessary repairs.  If the purchase option is not exercised, Medicare will make a total of 15 rental payments.  After 15 rental payments, the item must be provided without charge, other than a semi-annual maintenance and servicing fee, as long as it is medically necessary or until Medicare coverage ceases.

Home Health Care Medicare Guidelines   

Home Health Care is skilled medical care and other health care services that the patient receives in their home for the treatment of an illness or injury.  

To qualify for care under Medicare, the patient must have a specific care need, determined by a physician, requiring part-time or intermittent care (not full time), skilled nursing care, physical therapy, or speech language pathology services.  The patient must also meet the Medicare definition of "homebound": Leaving home must be a "taxing and considerable" effort and require the assistance of others of of a supportive device.  Absences from home for non-medical reasons must be infrequent and for a short duration.

Medicare will pay for Skilled Nursing Care, which are those services that can only be performed safely and effectively by a licensed nurse, such as IV infusions, IM/SQ/ID injections, wound care, NP/Trach care, Foley catheter care, gastrostomy tube care.  Also included in Skilled Nursing Care is teaching and training for disease process, medications/medication regimen, specified procedures (Injections, catheterization, wound, diabetic, and ostomy care) enteral/parenteral feedings, bowel/bladder training, and, observation and assessment of fluctuating vital signs, weight changes, edema, symptoms of drug toxicity, respiratory changes, circulatory changes, initiation of medical gases, post-hospital follow up.  

Home Health Aid Services, such as personal care and grooming, bathing, using the toilet, transfers/ambulation, can also be provided to clients who require assistance with activities of daily living, if the client is also receiving care from a qualifying skilled professional.  

If a patients social, emotional or economic situation impacts their ability to recover or to reach maximum rehab potential, Medical Social Services can also be provided, but do not qualify as a skill and cannot stand alone as the only home care service.  The need must be at a level requiring the intervention of a trained social worker for assessment of social emotional factors, counseling for long-range planning and decision making, education about or assistance in accessing community resources, short term counseling.

Service may be indicated for Speech Therapy if the skills of a trained therapist are required by the client to restore speech.  Physical and Occupational Therapy Services may be indicated if the skills of a trained therapist are required by a patient to restore movement and strength to an injured arm or leg, and learning new techniques for eating, dressing and performing other routine tasks to help achieve independence in daily living.  Therapy may be provided as often and as long as it is medically necessary and reasonable, even if the patient no longer needs other skilled care.

Medicare does not cover:

• 24-hour care at home
• self-administered prescription drugs
• meals delivered to the home
• homemaker services such as shopping, cleaning, laundry.
• personal care provided by home health aids, such as bathing, toileting, or providing help in getting dressed when this is the only care needed.  Medicare classifies this as "custodial care" because it could be provided safely and reasonably by people without professional skills and training.  Medicare does not pay for custodial care unless the patient is also getting skilled care or therapy and the custodial care is related to the treatment of the illness or injury.

Homemaker and Companion Services (non-medical)  

A homemaker performs household chores that include housekeeping, meal planning and preparation, shopping assistance, and routine household activities.

In addition to the above, a companion may provide companionship and accompany the client to doctors' appointments, other trips and outings.  

A homemaker and companion may assist a client with their personal care, but they do not provide hands on personal care to a client.

A homemaker and companion may provide medication monitoring and reminder, but may not administer medications.  

All personnel of a Homemaker/Companion Agency who enter the home of a client in the capacity of their employment must undergo a complete criminal history screening by the Agency for Health Care Administration (AHCA).  (However, an individual providing homemaker and companion services on their own, with no other help, does not need to be registered with AHCA, and is not required to carry insurance or go through any screening)  

Medicare does not cover homemaker/companion services.

Skilled Nursing Facility Admission Requirements  

Skilled nursing facility (SNF) provides 24-hour nursing care on a long and short term basis.  Additional services provided include physical therapy, occupational therapy, speech and language therapy, respiratory therapy and recreational therapy.  Skilled nursing services can also be be provided in acute care hospitals as well as skilled nursing facilities.  In the hospital setting, these units are also known as skilled nursing units (SNU), transitional care units (TCU) or sub-acute care units (SCU)  

Medicare provides coverage for patients in a skilled setting when they no longer need intensive hospital care, but still require nursing care or rehabilitation services on a daily basis.  For the purposes of Medicare coverage, a three-night (minimum) hospital stay is required prior to admission, and Medicare SNF benefits must be available*.  The patient must require services related to the condition treated in the hospital, and have Medicare SNF benefit days available.  Admission to a SNF following hospitalization must occur within 30 days of hospital discharge.

NOTE: * Medicare Part A covers up to a maximum of 100 days in a Medicare-certified SNF (as long as the patient has not used his/her SNF benefits within the 60 days prior to hospitalization).  If a patient has utilized a portion of their SNF benefits within that 60-day period, the available SNF benefit days are prorated based on unused days.  Part A benefits cover 100% of required services in a SNF for the first 20 days (as long as Medicare criteria is met).  From day 21 through day 100, benefit recipients have a $114/day co-pay responsibility (co-pay can be paid for privately, by supplemental insurance, or Medicaid); all other costs are provided by Medicare.

Transportation Services Guidelines  

Dial-A-Ride/Taxi/Wheelchair: These transportation services are not covered under Medicare or private insurance.  All costs are the responsibility of the individual, guardian, power-of-attorney, or family member.  Medicaid will pay for wheelchair van transportation for those receiving Medicaid benefits.  Dial-A-Ride bus services are intended for independent living residents are are available on a limited basis.

Seniors on the Go: The Charlotte County Council on Aging offers this special program that provides free transportation for low-income individuals.  Applications and  information can be received by calling (941) 627-2177.

Stretcher/Ambulance: Stretcher transportation for comfort of convenience is not a covered benefit under Medicare or private insurance.  These costs are the responsibility of the individual.  In most cases, a patient requires a stretcher for a medical condition or for safety.

Important Note!

• Medicare Patients requiring a stretcher for transport from a hospital to a SNF, rehab facility, or home (i.e. hospice) have benefits covering the costs of transportation by ambulance if they meet the criteria for "medical necessity".  These stretcher patients are transported by ambulance with two medical professionals and Medicare is billed, eliminating their out-of-pocket costs entirely if they have a Medicare supplement.

• Medicare residents requiring a stretcher for transportation from the SNF to their home, dialysis, hospital emergency care center, or hospital for a medical procedure should be transported by ambulance.  Medicare requires the patient to be bed confined (unable to get up from bed without assistance, unable to ambulate, unable to sit in a chair or wheelchair) or have running IVs, (note: all IV patients are mandated by law to be transported by ambulance regardless of ambulatory status), EKG monitors, high-flow O2, or require other specialized care or equipment.  If the patient is unsafe for transport via wheelchair or needs to be monitored or observed by a medical professional during transport, an ambulance should be requested.  The ambulance transport company will not bill Medicare for ambulance service if it does not meet "medical necessity".  The patient will still benefit by receiving a higher level of care at the cost of stretcher service.  Contact your local ambulance provider with any questions concerning your patients condition or need for ambulance transport.

Ambulance: A private ambulance company should be called for all resident non-emergency transports via stretcher from the skilled nursing or assisted living facility.  Hospital destinations for emergency room or outpatient services: cardiac catheterization, CT scans, MRI, ambulatory surgery, angiography, radiation therapy, or lymphatic & venous procedures are covered services for transport via ambulance under Medicare.  If a resident experiences a significant or unexplained decline in condition, falls without trauma, has IV's, undefined pain, requires replacement or reinsertion of PEG tubes, do not call "911".  They are NOT true emergencies!

For ALL trauma care, shock, severe bleeding, respiratory or cardiac distress,
call "911" for immediate medical attention