WHAT IS NEEDED TO QUALIFY FOR MEDICARE HOME HEALTH COVERAGE?
- The patient must be homebound. (This does not mean the patient can never leave home. For example, patients can leave home occasionally, go to adult day care, religious services, medical appointments, special occasions);
- The patient must require skilled nursing on an intermittent basis (from once a day for finite, recurring periods of 21 days at a time, to once every 60 days), or physical therapy, speech language pathology – or occupational therapy to continue care;
- A physician must order the care and sign a “Plan of Care;”
- A physician or appropriate non-physician health care professional must have seen the patient face-to-face prior to certifying the need for home health services;
- Documentation about the face-to-face meeting must be included in the home health care certification, signed by a physician; and
- The care must be provided by, or under arrangements with, a Medicare-certified home health agency.
WHAT SERVICES WILL MEDICARE COVER?
- Part-time or intermittent nursing care provided by or under the supervision of a registered nurse; *
- Physical therapy, occupational therapy, and speech language pathology;
- Part-time or intermittent home health aides, to provide hands-on personal care services; *
- Medical social services provided under the direction of a physician; and
- Medical supplies such as wound dressings when ordered by a physician as part of a patient’s care;
THE PATIENT DOES NOT HAVE TO IMPROVE TO QUALIFY FOR MEDICARE COVERAGE
- Medicare coverage does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the need for skilled care.
- It is not necessary for the patient to improve in order to qualify for Medicare coverage. The patient can have a chronic or long-term condition.
- Skilled nursing and/or therapy to maintain a patient’s condition, or to slow decline, can be covered by Medicare.
- Under the law, Medicare can cover up to 28 hours combined of home health aide and nursing. (Up to 35 hours, on a case-by-case basis if needed).
UNFAIR DENIALS OF MEDICARE OCCUR WITH SURPRISING FREQUENCY
Because Medicare administrators sometimes use rules and procedures which may improperly restrict coverage and payment, patients are sometimes denied coverage and required to pay for care which should be covered by Medicare.
WHAT TO DO IF MEDICARE COVERAGE IS ENDING OR DENIED
- If the home health agency issues a notice that states services will be ending, the patient has a right to an expedited appeal when “a physician certifies that failure to continue the provision of such services is likely to place [the patient’s] health at significant risk.”
- Ask the patient’s doctor to instruct the home health agency to continue to provide necessary services. Home health care should not be ended or reduced unless the change has been ordered by the doctor.
- The home health agency must give at least two days advanced notice before ending services. A request for an expedited review, orally or in writing, must be made by noon of the next calendar day to preserve expedited appeal rights.
- If the patient receives a written denial from the home health agency, ask the agency, in writing, to submit the claim to Medicare for a coverage determination from Medicare. Sometimes coverage will be granted. If not, further appeal is then possible.
IMPORTANT ADVOCACY TIPS
- There is no legal limit to the duration of Medicare home health coverage for people who continue to meet the coverage criteria. Medicare coverage is available for necessary home health care even if it extends over a long period of time.
- Do not accept arbitrary caps on coverage. For example, do not accept assertions that home health aide services in excess of one visit per day or week cannot be covered.
- Family members cannot be required to provide care in order for the beneficiary to obtain Medicare coverage – and beneficiaries cannot be required to accept care from family members.
- In order to appeal a Medicare denial, the home health agency must file a Medicare claim for the patient’s care. If the patient wants to pursue coverage, he/she should tell the home health agency to file a Medicare claim, even if the agency thinks Medicare coverage is not available.
- If the beneficiary requests, the home health agency must submit the claim to Medicare. (But the beneficiary can be required to pay pending Medicare’s decision, and if Medicare is denied.)
- The doctor is the patient’s most important ally. If it appears that Medicare coverage will be denied, ask the doctor who ordered the care to help explain the need for the care.
Restoration potential is not required to obtain Medicare coverage.
MEDICARE CAN BE AVAILABLE if:
- A skilled professional is needed to maintain current capabilities or prevent further deterioration.
Medicare coverage should not be denied:
- Simply because the individual’s condition will not improve, is chronic, or expected to last a long time.
Contact CHOICES, (800) 994-9422 or the Center for Medicare Advocacy, (860) 456-7790.
CENTER FOR MEDICARE ADVOCACY, INC.
The Center for Medicare Advocacy, founded in 1986, is a national non-profit law organization that works to ensure fair access to Medicare and quality health care. The Center is based in Connecticut and Washington, DC, with offices around the country.
Based on our work with real people, the Center advocates for policies and systemic change that will benefit all those in need of health care coverage and services.
Staffed by attorneys, legal assistants, nurses, and information management experts, the organization represents thousands of individuals in appeals of Medicare denials. The work of the Center also includes responding to over 7,000 calls and emails annually from older adults, people with disabilities, and their families, and partnering with CHOICES, the Connecticut State health insurance program (SHIP).
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Produced under a grant from the Connecticut State Unit on Aging in conjunction with the CHOICES Program
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