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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, certifying that the services are medically necessary; the physician must also certify that there has been a face-to-face encounter with the patient’ within 90 days prior to the start of care or within 30 days after the start of care.
- The patient is homebound. This criterion is generally met if non-medical absences from home are infrequent and 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 "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 (less than 7 days per week but at least once every 60 days) or skilled physical therapy, speech therapy, or continuing occupational therapy. Daily skilled nursing care is available for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional daily skilled nursing is finite and predictable).
- 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;
- Part-time or intermittent services of a home health aide, and;
- Durable medical equipment (DME) and medical supplies
- 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 medically 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 criteria 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 health 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 (BFCC-QIO) (site visited September 24, 2015).
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:
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)]
In a rule that became effective on November 19, 2013, CMS made a significant revision to its homebound policy. The change reformulates the language from the agency’s old policy into a two-part criteria for determining whether a patient meets the definition of being confined to the home in order to be eligible for the Medicare home health benefit:
The patient must either:
- Because of illness or injury, need the aid of supportive devices such as
crutches, canes, wheelchairs, and walkers; the use of special transportation; or
the assistance of another person in order to leave their place of residence
- Have a condition such that leaving his or her home is medically
If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet
two additional requirements defined in Criteria-Two below.
- There must exist a normal inability to leave home;
- Leaving home must require a considerable and taxing effort.
We believe that the problem with this new policy is that some patients may be homebound even if they do not require some sort of assistance to leave their residences. For example, a patient might have severe chronic obstructive pulmonary disease (COPD) that makes it difficult for her to breathe when she exerts herself. If this patient does not require a supportive device like a cane or walker, special transportation, or assistance of another person, she would be ineligible for the Medicare home health benefit under the new rule because she cannot meet Criteria-One (assuming that leaving home with COPD is not contraindicated). Under the prior rule, which made the “normal inability to leave home” and “considerable and taxing effort” language the main criteria in defining homebound, the patient’s pulmonary difficulties might have been enough on its own to establish homebound status.
When contesting denials of care or coverage based on homebound status, we encourage beneficiaries and their advocates to utilize the helpful examples of conditions in the policy manual that may indicate that a patient cannot leave the home. We also believe it could be useful to refer home health agencies and contractors to CMS’ earlier guidance to take a more flexible, fair, and realistic approach to evaluating whether a chronically disabled individual is homebound.
In 2002, the Secretary of the United States Department of Health and Human Services, Tommy Thompson, made changes to the Medicare Home Health Agency Manual and directed Medicare providers and contractors to be more flexible in applying the Medicare homebound criteria.
In particular, the Medicare Home Health Agency Manual, § 30.1.1, was amended to provide additional, not all inclusive examples of non-medical absences (e.g., family reunion, funeral, graduation) that would not disqualify a person from being considered homebound. The Manual currently includes the following language:
In determining whether the patient has the general ability to leave the home and leaves the home only infrequently or for periods of short duration, it is necessary (as is the case 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 (meeting both criteria listed above) more frequently during a short period when the patient has multiple medical appointments with health care professionals and medical tests in 1 week. 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.
This direction from CMS to look at a long view, not a limited snapshot, to determine whether the beneficiary meets the homebound standard is 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 additional language does not alter the existing homebound criteria, it provides 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 (see here: http://archive.hhs.gov/news/press/2002pres/20020726d.html (site visited October 7, 2015) and the manual language to help make these points when clients are erroneously denied coverage.
THE IMPOVEMENT STANDARD AND HOME HEALTH
The Medicare Benefit Policy Manual highlights that any physical, speech, or occupational therapy is a skilled therapy service if the complexity of the service is such that it can only be performed safely and/or effectively under the supervision of a skilled therapist. In order for a therapy to be considered reasonable and necessary, the skilled therapy must be consistent with the severity and nature of the illness or injury as well as the beneficiary’s particular needs. (MBP Manual, Ch. 7, § 40.2.1, available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf, site visited September 24, 2015).
The case Jimmo v. Sebelius guarantees in law that homebound skilled nursing or therapy is appropriate for the purposes of maintenance as well as to slow down a patient’s quick decline. Even as CMS said that it never had an “improvement standard,” many Medicare denials continue to be based on the expectation that a patient will not improve. Despite this, the Jimmo case made clear that a patient’s restorative potential is not required by law and homebound skilled nursing and therapy for the purposes of maintenance and slowing a steep declination in health are perfectly acceptable.
- The Center for Medicare and Medicaid Services’ manual provision that refutes the Improvement Standard can be found here (site visited September 24, 2015)
- For more information on Jimmo and the Improvement Standard, see here (site visited September 24, 2015)
The Improvement Standard, however, continues to be used to justify denying homebound nursing and therapy services. Should care be improperly denied, you can access a re-review form here (site visited September 24, 2015). Our website also includes various self-help packets should an appeal become necessary (site visited September 24, 2015).
- Center for Medicare Advocacy Launches Home Health Access Initiative To Open Doors to Home Health Care September 15, 2016
- Submit Your Home Health Access Story September 15, 2016
- The Promise of Medicare Home Health Coverage September 13, 2016
- Proposed Rules Will Add to Problems Accessing Necessary Home Health Care August 24, 2016
- Center Comments on Medicare Prior Authorization of Home Health Services Demonstration April 6, 2016
- Medicare’s Home Health Benefit Under Threat March 2, 2016
- Comments on Proposed Rules: CY 2016 Home Health Prospective Payment System Rate Update; home Health Value-Based Purchasing Model; and Home Health Quality reporting Requirements September 1, 2015
- 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
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