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  1. Home for the Holidays: Leaving the Nursing Home During a Medicare-Covered Stay
  2. Home Health Issue Brief
  3. Checklist for Medicare Home Health “Improvement Standard” Denials
  4. Home Health Aide Coverage Continues to Shrink in Traditional Medicare While CMS Enhances it in Medicare Advantage
  5. Successful Advocacy for Home Health Beneficiary in Need of Maintenance Physical Therapy
  6. Home Health Telephone Survey

Home for the Holidays: Leaving the Nursing Home During a Medicare-Covered Stay

Late November begins a time for gatherings with family and friends – Thanksgiving, soon followed by the December holidays. Nursing home residents often want to participate in these gatherings but may worry that they will lose Medicare coverage if they leave the facility to do so. Residents and their families and friends can put their minds at ease. According to Medicare law, nursing home residents may leave their facility for family events without losing their Medicare coverage. However, depending on the length of their absence, beneficiaries may be charged a "bed hold" fee by their skilled nursing facility (SNF).

The Medicare Benefit Policy Manual recognizes that although most beneficiaries are unable to leave their facility,

an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care. [1]

The Manual elaborates: "Decisions in these cases should be based on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences." [2] However, a facility should NOT notify patients that leaving the facility will lead to loss of Medicare coverage. The Medicare Benefit Policy Manual says that such a notice is "not appropriate." [3]

If the resident begins a leave of absence and returns to the facility by midnight of the same day, the facility can bill Medicare for the day's stay. [4] If the resident is gone overnight (i.e., past midnight) and returns to the facility the next day, the day the resident leaves is considered a leave of absence day. Clarifying what seemed to be conflicting provisions in the Manuals, the Centers for Medicare & Medicaid Services (CMS) confirms that the facility can bill a beneficiary for bed-hold days during a temporary SNF absence. [5]

Chapter 6 of the Medicare Claims Processing Manual provides that the facility cannot bill a beneficiary during a leave of absence, "except as provided in Chapter 1 of the manual at §30.1.1.1." [6] As required by the federal Nursing Home Reform Law, [7] that section authorizes SNFs to bill a beneficiary for bed-hold during a temporary "SNF Absence" if the SNF informs the resident in advance of the option to make bed-hold payments and of the amount of the charge and if the resident "affirmatively elect[s]" to make bed-hold payments prior to being billed. [8]

The Manual states that a facility “cannot simply deem a resident to have opted to make such payments and then automatically bill for them upon the resident’s departure from the facility.”  [9] Charges to hold a bed and maintain the resident's "personal effects in a particular living space that the resident has temporarily vacated… are calculated on the basis of a per diem bed-hold payment rate multiplied by however many days the resident is absent, as opposed to assessing the resident a fixed sum at the time of departure from the facility." [10] CMS distinguishes bed-hold payments from payments for admission or readmission, which are "not allowed." [11]

In summary, residents can leave their SNFs for short periods, such as a day or two, to enjoy gatherings with their families and friends without losing Medicare coverage. However, SNFs are allowed to bill residents to reserve their beds so long as they advised residents in advance of the charges to hold the bed and the residents have agreed, in advance, to make the payments.

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[1] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, second paragraph) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf). Scroll down to page 43.
[2] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, second paragraph) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf). Scroll down to page 43.
[3] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, third paragraph) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf). Scroll down to page 43.
[4] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 3, §20.1.2. (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c03.pdf). Scroll down to page 4.
[5] Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, §40.3.5.2. (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf). Scroll down to page 45. Note, unlike Medicaid in some states, the Medicare program does not provide any payment for "bed-hold."
[6] Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, §40.3.5.2. (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf). Scroll down to page 45.
[7] 42 U.S.C. §1395i-3(c)(1)(B)(iii), 42 C.F.R. §483.10(g)(17)-(18).
[8] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf). Scroll down to pages 46-47. CMS cites, as authority for this payment option, the Nursing Home Reform Law, 42 U.S.C. §1395i-3(c)(1)(B)(iii), and 42 C.F.R. §483.10(g)(17)-(18).
[9] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf). Scroll down to pages 46-47.
[10] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf), scroll down to pages 46-47.
[11] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf). Scroll down to pages 46-47.

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Home Health Issue Brief

Since 2017 the Center for Medicare Advocacy has been writing and disseminating a ten-part Home Health Issue Brief Series examining the growing crisis in access to Medicare-covered home health care, and outlining the Center’s work to address the issue. This Home Health Issue Brief includes all ten prior Briefs in one document. We hope this complete Brief will help advocates and policy-makers access the relevant, often unknown, Medicare law, and related resource material, and assist them in efforts to resist inappropriate barriers to covered care.

Download the complete Issue Brief at http://www.medicareadvocacy.org/wp-content/uploads/2018/11/HH-Issue-Brief-Full.pdf

We invite you to send comments about the issues raised here and submit Medicare home health stories to the Center at http://www.medicareadvocacy.org/submit-your-home-health-access-story/.

CMA Issue Brief Series: Medicare Home Health Care Crisis

  1. Overview – The Crisis in Medicare Home Health Coverage and Access to Care
  2. Medicare Home Health Coverage, Legally Defined
  3. Medicare Coverage for Home Care Is Based On a Need For Skilled Care – Improvement Is Not Required
  4. Misleading and Inaccurate CMS Medicare Home Health Publications
  5. The Home Care Crisis: An Elder Justice Issue
  6. Beneficiary Protections Expanded in Revised Home Health Conditions of Participation
  7. Barriers to Home Care Created by CMS Payment, Quality Measurement, and Fraud Investigation Systems
  8. Proposed CMS Rules and Systems Will Worsen the Home Care Crisis
  9. Statistical Trends and Published Articles with Studies and Research from 2002-2017
  10. Strategic Plans to Address and Resolve the Medicare Home Care Crisis

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Checklist for Medicare Home Health “Improvement Standard” Denials

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Checklist to help Medicare beneficiaries and their families respond to unfair Medicare denials for Medicare home health care based on an erroneous “Improvement Standard.” The Checklist outlines the coverage criteria for home health care and emphasizes language from the Jimmo Settlement Agreement.  Per the Settlement, the Centers for Medicare & Medicaid Services (CMS) revised the Medicare Benefit Policy Manual to clearly disavow any notion that individuals with Medicare who receive home health care must improve in order for their care to be covered by Medicare.

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Home Health Aide Coverage Continues to Shrink in Traditional Medicare While CMS Enhances it in Medicare Advantage

For years the Center for Medicare Advocacy and other stakeholders have advocated for Medicare coverage for home health aides without the current prerequisites that the individual be homebound and require skilled nursing or therapy. Unfortunately, the ability to get Medicare-covered home health aide care has greatly declined in recent years, even when individuals meet the homebound and skilled care requirements. Indeed, people are often told the most they can get is just a bath a few times a week.

Medicare law authorizes up to 35 hours a week of personal hands-on care and nursing services combined. Personal hands-on care does include bathing, but is also includes dressing, grooming feeding, toileting, and other key services to help an individual remain healthy and safe at home. This care used to be available. The Center helped many clients remain at home because these services were in place, but it is now almost never obtainable. Statistics demonstrate this point. In 2018 MedPAC reported that home health aide visits per 60-day episode of home care declined by 87% from 1998 to 2016, from an average of 13.4 visits per episode to 1.8 visits.  As a percent of total visits from 1997 to 2016, home health aides declined from 48% of total services to 10%. (MedPAC Report to Congress, p. 246, March 2018.) 

Instead of correcting this harmful misapplication of Medicare coverage for all beneficiaries, CMS recently issued a new policy allowing private Medicare Advantage (MA) plans to provide personal care services for their enrollees without a homebound or skilled care requirement. (CMS Memo, Reinterpretation of “Primarily Health Related” for Supplemental Benefits, April 27, 2018.) This is particularly ironic and unjust as advocates continue to challenge the limited interpretation of the Medicare home health benefit, particularly the reduction in home health aide coverage. While it remains to be seen how much this special MA personal care benefit will actually be offered and provided, it continues the trend of discriminating against the majority of beneficiaries, who are enrolled in traditional Medicare. It also adds to the myriad enticements from CMS for people to join private MA plans.

The new Congress should address this inequity as soon as possible. In general, legislation is needed that adds equivalent benefits in traditional Medicare to all those included in private Medicare Advantage. In particular, Congress should authorize Medicare coverage for home health aides to provide hands-on personal care without a homebound or skilled care requirement – the same benefit criteria now allowed for MA enrollees.

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Successful Advocacy for Home Health Beneficiary in Need of Maintenance Physical Therapy

Mrs. R contacted the Center for Medicare Advocacy about her husband, who has ALS, and was told his home health physical therapy was about to be terminated. While receiving physical therapy, Mr. R had reduced pain, allowing him to decrease pain medications, improved bowel function, and increased ability to clear airway secretions. Nonetheless, home health agency staff told him that while they would continue to provide nursing, the physical therapy was not reasonable and necessary and would be ending. Mrs. R questioned the agency about a maintenance therapy plan of care, and was told Medicare does not cover maintenance therapy, or at least not for someone with ALS. After Mrs. R showed the home health agency relevant components of the law, as provided by the Center, the agency claimed it simply did not provide maintenance care. The Center advocated for Mr. R by speaking with multiple representatives of the agency, including the Chief Clinical Officer and General Counsel, about Medicare coverage rules, maintenance care, and the Jimmo Settlement. The Center also coordinated a call with the home health agency and a physical therapist with expertise in maintenance therapy and necessary documentation. As a result of the Center’s advocacy, Mr. R is again receiving physical therapy at home.

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Home Health Telephone Survey

As part of a project supported by the Ossen Family Foundation, Center for Medicare Advocacy staff recently called the 16 home health agencies that, according to Medicare’s Home Health Compare tool, serve the two counties near our CT office. Home health agencies were asked about their ability to provide care to a beneficiary with a chronic condition (either ALS, MS, or Parkinson’s disease) who had a doctor’s order for physical therapy once a week, skilled nursing two times a week, and a home health aide twenty hours a week. The results of the survey present concerns about available Medicare-covered home care and accurate information for beneficiaries. Results include:

  • Only 2 of the 16 agencies surveyed said they could provide all the necessary care.  
  • 4 of the 16 agencies said they might be able to provide all the care, but would need to check the availability of home health aides, hire more aides to meet the need, and/or conduct an assessment.  
  • 5 of the 16 agencies said they either did not have any home health aides available for the area, or the aides would be limited to 1-3 hours per week. 
  • There were also multiple inaccuracies in the Home Health Compare information, including telephone numbers that were no longer in service and agencies that did not provide care in the area.

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