Medical and health care can be categorized as either skilled or unskilled. Skilled care is administered by a professional health care worker, with the expectation of improvement and achievement of treatment goals, and the implication of an eventual lack of requirement for care services. Unskilled care is mostly administered by nonprofessional workers, with the acknowledgement of an unlikelihood for improvement and an aim of maintaining the patient’s current health state (often care involves assistance with tasks of daily living, such as bathing, eating, etc.) Levels of care may be categorized as acute, sub acute, rehabilitation, skilled nursing, home health, and outpatient. Acute care is characterized by the requirement of ongoing skilled care. Sub acute care provides a lower intensity of care than acute, and daily skilled care is typically administered at a nursing home or SNF (skilled nursing facility.) Home care provides intermittent skilled care. If the patient meets a criterion which includes the ability to undergo three hours of rehab five days a week, he may qualify for inpatient rehabilitation care. If he fails to meet criteria, rehab may also be available in other facilities. An important aspect of a case manager’s job is the efficient progression through the levels of care and the treatment plan.Medicare only provides coverage for unskilled care when it is part of a skilled care treatment plan. Case managers must be familiar with the levels of care for their clients. Medicare provides coverage for SNF’s or nursing homes when assessed as medically necessary and within thirty days of a three-day hospitalization. The Medicare benefit period covers 100 days of skilled nursing, during which the patient is responsible for copays ($101.50 per day) for days twenty one through the duration of the covered period. Medicare coverage of home health services requires that the patient be home bound and need intermittent skilled services (such as nursing or respiratory assistance). Bathroom equipment is not covered, and equipment that is covered requires a 20% copay. Individuals diagnosed with terminal illnesses have the option of Medicare coverage of Hospice care, which includes: pain relief, physical therapy, nursing and supportive services, and symptom management; a $5 copay for medication and $5 copay for inpatient respite care is required.
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