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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.
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.
Medicare coverage should not be denied simply because the patient's condition is "chronic" or "stable." "Restorative potential" is not necessary.
Resist arbitrary caps on coverage imposed by the intermediary. For example, do not accept provider or intermediary assertions that aide services in excess of one visit per day are not covered, or that daily nursing visits can never be covered.
There is no legal limit to the duration of the Medicare home health benefit, Medicare coverage is available for necessary home care even if it is to extend over a long period of time.
The doctor is the patient's most important ally. If it appears that Medicare coverage will be denied, ask the doctor to help demonstrate that the standards above are met. Home care services should not be ended or reduced unless it has been ordered by the doctor.
In order to be able to appeal a Medicare denial, the home health agency must have filed a Medicare claim for the patient's care. Request, in writing, that the home health agency file a Medicare claim even if the agency insists that Medicare will deny coverage.
1. Review the Medicare home health qualifying criteria in the Center's Home Health Quick Screen above. If you meet these criteria follow the advocacy steps below.
2. Contact your treating physician, inform him or her of what is happening, and ask for support of the need for the services currently ordered. The treating physician should be the person who decides whether home health services are necessary and whether they should be reduced or terminated.
- If the physician is able to help, request a written statement explaining the on-going need for the services and that the medical circumstances leading to the doctor's order for services are still present. Ask the physician not to sign a discharge order for home health services if s/he continues to think the services are medically appropriate.
3. If your home helath care will be inappropriately discontinued, follow the steps outlined in the home health expedited appeal Self Help Packet.
4. Request that the home health agency hold a meeting with the patient and family prior to any termination or reduction in services to discuss the appropriateness of the proposed action.
5. If the home health agency has provided poor care or has treated the patient inappropriately, contact your state's Quality Improvement Organization (QIO).
Sections 501-508 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) amended 42 U.S.C. '' 1395f(n), 1395(n), 1395fff(b), 1395(x)(v) to modify the Medicare home health benefit. (Public Law 106-554, 12/21/2000.) The provisions discussed below clarified the threshold "homebound" criteria, making clear that individuals who attend adult day care or religious services may also qualify for Medicare home health coverage. These changes became effective upon date of enactment, December 21, 2000.
The statutory language clarified and broadened the homebound eligibility criterion in two ways:
Absences attributable to the need to receive health care treatment, including regular absences to participate in therapeutic, psychosocial, or medical treatment at a licensed or accredited adult day-care program, will not disqualify a beneficiary from being considered homebound. For many years beneficiaries who attended adult day-care programs were routinely denied home health services.
Absences for the purpose of attending a religious service are deemed to be absences of infrequent or short duration. (Generally a beneficiary whose absences from the home are not considered infrequent or of short duration will not be considered to be homebound.)
The Current Homebound Definition in the Medicare Act reads as follows (language added by BIPA is in italics):
An individual shall be considered to be "confined to his home" if the individual has a condition, due to an illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive devise (such as crutches, a cane, a wheelchair or a walker), or if the individual has a condition such that leaving his or her home is medically contraindicated. While an individual does not have to be bedridden to be considered "confined to his home", the condition of the individual should be such that there exists a normal inability to leave home, that leaving home requires a considerable and taxing effort by the individual, any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not disqualify an individual from being considered to be "confined to his home". Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to an absence of infrequent or short duration. [42 U.S.C. ‘1395n(a)(2)(F)]
On July 26, 2002 Tommy Thompson, Secretary of the United States Department of Health and Human Services, issued a press release and changes to the Medicare Home Health Agency Manual. The Secretary directed Medicare providers and contractors to be more flexible in applying the Medicare homebound criteria. This is important to elders and disabled Medicare beneficiaries as an individual must be confined to home (homebound) in order to qualify for Medicare home health coverage.
In particular, the Medicare Home Health Agency Manual, §§204.1-204.2, was amended to include additional, not all inclusive examples of situations in which the homebound criteria is met. (Family reunion, funeral, graduation.) More importantly, the following general language was added to the Manual:
It is necessary (as in determining whether skilled nursing services are intermittent) to look at the patient's condition over a period of time rather than for short periods within the home health stay. For example, a patient may leave the home (under the conditions described above, e.g. severe and taxing effort, with the assistance of others) more frequently during a short period when, for example, the presence of visiting relatives provides a unique opportunity for such absences, than is normally the case. So long as the patient's overall condition and experience is such that he or she meets these qualifications, he or she should be considered confined to home. (Emphasis added)
Although the new examples may be helpful in particular cases, this new direction from CMS to look at a long view, not a limited snapshot, to determine whether the beneficiary meets the coverage standard (for intermittent nursing as well as homebound) is most significant. Advocates have long maintained that cases should be reviewed, and qualification for coverage judged, by looking at services provided over the course of a year, not in fragmented 1-2 month segments.
While the new language does not really add to the already existing homebound criteria, it does provide important direction that the criteria are to be applied flexibly and with a broad view of the patents’ condition. Advocates should use the Secretary’s press release language and the manual language to help make these points when clients are erroneously denied coverage.
A copy of the Secretary’s press release and Manual revisions are available from the Center for Medicare Advocacy (860)456-7790 and on the Centers for Medicare & Medicaid Services web site.
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- Case Study: Home Health Coverage and Medicare Advantage Plan Responsibilities August 13, 2015
- New CMS Proposed Homebound Policy Would Leave Medicare Beneficiaries Without Coverage November 7, 2013
- Caution: Home Health Episode Payment Caps October 10, 2013
- Self Help Packet for Home Health Care Appeals Including “Improvement Standard” Denials February 22, 2013
- Warning: Medicare Payment Limits Are Bad for Health! December 13, 2012
- Annual Medicare Payment Limits for Home Health – Even Worse Than Co-Pays for Beneficiaries December 5, 2012
- Home Health Face-to-Face Physician/Practitioner Requirement Challenges April 12, 2012
- New Home Health and Hospice Face-to-Face Physician/Practitioner Encounter Requirement January 13, 2011
- A Client Profile January 1, 2010
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