Medicare's Rules for Eligibility for Home Healthcare Services

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Medicare has been the single largest payer of home healthcare services, although Medicaid is catching up. Medicare home healthcare services are largely home health visits, whereas Medicaid's are mostly in the category of personal care visits. Because Medicaid home care varies by state, start your search with Medicare. For people who are eligible for both programs (the duals), Medicare is the first payer.

Medicare's eligibility rules are fairly stringent:

  • You or your parent must be under a doctor's care, and the doctor must have established a plan of care that is reviewed regularly. The doctor must have examined you within the previous 30 days. In Medicare terminology, this is called a “face-to-face” visit.

  • The doctor must certify that you need one or more of the following skilled services:

    • Intermittent (part-time) skilled nursing care (fewer than eight hours a day over a period of 21 days or fewer than seven days a week)

    • Physical therapy

    • Speech language-pathology services

    • Continued occupational therapy (although OT, which involves therapy to restore function for everyday tasks, is not a skilled service that makes you eligible for home care on its own.)

    These therapy services must be specific, safe, and effective for your condition and be performed only by qualified therapists, and the amount, frequency, and duration of the services must be reasonable.

  • The doctor must certify that you are homebound, which means that:

    • It is not recommended that you leave the home because of your condition.

    • You need help (such as using a wheelchair, walker, special transportation) or someone else's assistance.

    • Leaving home requires a considerable and taxing effort.

    • You can leave home only for medical treatment or short, occasional absences for nonmedical reasons. You can even go to adult day care, but the home care services will be provided in your home.

  • Medical social services to help with social and emotional concerns related to illness are covered. However, many home care agencies have limited social work staff.

  • Some medical supplies, like wound dressings, are covered when they are ordered as part of your care. Durable medical equipment is covered separately.

  • Finally, as already noted, these services must be provided by a Medicare-certified Home Health Agency (HHA).

If you qualify for Medicare home healthcare services, you may also be eligible for some home health aide services. This bears repeating: Medicare does not cover aide services unless you are also getting skilled care services. Aides provide personal care and some tasks like making lunch and taking care of the individual's laundry (not the family's lunch or laundry).

Duration of home healthcare services under Medicare

Under Medicare, home health agencies receive payment based on a 60-day episode of care. Some cases require the full 60 days of expensive care; other cases are closed in a shorter period and require mostly routine care. Under this prospective payment system, agencies have an incentive to close cases rather than keep them open.

If your doctor refers you or your parent for home healthcare services, a nurse from the agency will come to the home to do an evaluation. An agency does not have to accept the case if it can't offer the needed services, the home is not safe, or for other reasons. The agency, however, cannot discriminate on the basis of race, religion, or other personal characteristics.

Based on the evaluation, the nurse determines where you or your parent fit into one of 153 home health resource groups (HHRGs). (If fewer than five home care visits are expected to be necessary, the case is not included in these categories.) Where you fit in this complicated scheme plays a part in how long the episode of care lasts.

On average, Medicare home healthcare clients have two episodes of care per year (not necessarily consecutive and not necessarily lasting 60 days). Each episode of care involves an average of 17 visits, 80 percent of them by a nurse or therapist. Home health aide visits account for only about 15 percent of visits.

What does this mean in practice? As an example, the nurse who does the evaluation may recommend a schedule of services, including a nurse visit two to three times a week, a physical therapist twice a week, and a home health aide for four visits a week of two to three hours each. This schedule will be reviewed and may be changed weekly.

Some home healthcare services can go on for a longer period, for example, for treating chronic obstructive pulmonary disease (COPD) or continuing occupational therapy. A doctor can recertify a person for home care services, although the continuing need for skilled services will have to be documented.

Appealing Medicare decisions on home care

Home health agencies are required to give you advance notice (a Home Health Advance Beneficiary Notice, or HHABN) in the following situations:

  • When you will be receiving medical services and supplies that Medicare doesn't pay for; you will have to agree to pay for these services on your own.

  • When you're required to make a 20 percent copayment of the Medicare-approved amount for medical equipment, such as wheelchairs, walkers, and oxygen equipment. The Medicare-approved amount may not be the same as the supplier's bill.

  • When the HHA reduces or stops providing you with some services or supplies because the doctor has changed the orders.

  • When the home health agency plans to give you a home health service or supplies that Medicare probably won't pay for. (The determination that Medicare won't pay is made by a contractor, not Medicare itself. These are insurance companies under contract to Medicare to review claims.)

Starting in 2014, claims for continuing rehabilitation services cannot be denied by an assertion that the patient is not improving. The Medicare standard is whether a skilled service such as physical therapy is needed to prevent or delay deterioration, not whether the person is going to get better.

The home health agency is supposed to give you a written document called a Notice of Medicare Provider Non-Coverage at least two days before all covered services end. The notice should tell you the date all your covered services will end and how to ask for a fast appeal through the regional quality improvement organization (QIO).

Not all home health agencies provide the required notices in a written form or even in advance. The nurse or aide may simply tell you one day, “This is my last visit.” If this happens, you can complain to the QIO. But try to keep on top of the situation by asking the nurse to give you an estimate of how long services will last. In general, think weeks, not months.

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