Medicare Coverage of Home Health Care
It is important for beneficiaries and advocates to know what Medicare home health coverage should be under the law, especially for those with long term, chronic, and debilitating conditions.
Home Health Access Issues
The Center has been hearing from people unable to access Medicare-covered home health care, or the appropriate amount of care, despite meeting Medicare coverage criteria.
In particular, people living with long-term and debilitating conditions find themselves facing significant access problems. For example, patients have been told Medicare will only cover one to five hours per week of home health aide services, or only one bath per week, or that they aren’t homebound (because they roam outside due to dementia), or that they must first decline before therapy can commence (or recommence). Consequently, these individuals and their families are struggling with too little care, or no care at all.
Home health access problems have ebbed and flowed over the years, depending on the reigning payment mechanisms, systemic pressures, and misinformation about Medicare home health coverage. Regrettably, if recent policies and proposed rules are fully implemented, it appears these access problems will only get worse.
To respond to this crisis, the Center is building a coalition to support a Home Health Access Initiative. With support from Team Gleason, the ALS Association, the Christopher and Dana Reeve Foundation and the John A. Hartford Foundation, this Initiative will oppose inappropriate restrictions on Medicare to open doors to Medicare-covered, necessary home care, but we need your help.
If you or someone you know has experienced home health care access issues, submit the story today.
What Home Health Care is Covered Under Medicare
If the triggering conditions below 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
How to Know if Medicare Should Cover Your Home Health Care
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.
- 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.
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)]
Centers for Medicare & Medicaid Services (CMS) Policy is More Restrictive than the Law
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 contraindicated.
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.
Advocacy Tips for Home Health Reductions & Terminations
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).
Note on appeals based on 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.
White Paper: The Promise and Failure of Medicare Home Health Coverage
The Center for Medicare Advocacy has been hearing from people who meet Medicare coverage criteria but are unable to access Medicare-covered home health care, or the appropriate amount of care. These problems have been escalating. Care provided often falls short of care that is covered under the law and ordered by the physician. There are no practical solutions to obtain care or protections to prevent discharge from care. Many who are unable to access care are unable to stay at home.
Articles & Updates
- Alert – Spotlight on Medicare Home Health Care; Tax Cuts Set Stage for Medicare/Medicaid Cuts; ACA News Nov 8, 2017
- New Medicare Payment Model Puts People Who Need Home Care in Jeopardy Nov 2, 2017
- Center Comments on Proposed Home Health Payment Rules Sep 25, 2017
- CMA Alert – Critical Issue Roundup: MA Overpayment; HH Payment; Observation; More Aug 16, 2017
- The Home Care Crisis: An Elder Justice Issue Aug 2, 2017
- CMA Alert – Senate Health Bill, Again; Medicare Trustees Report; HH CoPs; More Jul 13, 2017
- Medicare Home Health Coverage Should Be Based on the Need for Skilled Care – Improvement Is Not Required May 31, 2017
- Brief Description of Medicare Home Health Coverage Under the Medicare Act May 3, 2017
- Overview: The Crisis in Medicare Home Health Coverage and Access to Care Apr 19, 2017
- Home Health Feb 27, 2017
- The Promise and Failure of Medicare Home Health Coverage Dec 15, 2016
- The Promise and Failure of Medicare Home Health Coverage Dec 15, 2016
- Medicare Home Health Benefit’s Face-to-Face Encounter Requirement Nov 8, 2016
- An Open Letter to CMS About Fraud Sep 28, 2016
- Center for Medicare Advocacy Launches Home Health Access Initiative To Open Doors to Home Health Care Sep 15, 2016
- The Promise of Medicare Home Health Coverage Sep 13, 2016
- Center Comments on Proposed Home Health Payment Changes Aug 29, 2016
- Proposed Rules Will Add to Problems Accessing Necessary Home Health Care Aug 24, 2016
- Center Comments on Medicare Prior Authorization of Home Health Services Demonstration Apr 6, 2016
- Medicare’s Home Health Benefit Under Threat Mar 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 Sep 1, 2015
- Case Study: Home Health Coverage and Medicare Advantage Plan Responsibilities Aug 13, 2015
- New CMS Proposed Homebound Policy Would Leave Medicare Beneficiaries Without Coverage Nov 7, 2013
- Caution: Home Health Episode Payment Caps Oct 10, 2013
- Warning: Medicare Payment Limits Are Bad for Health! Dec 13, 2012
- Annual Medicare Payment Limits for Home Health – Even Worse Than Co-Pays for Beneficiaries Dec 5, 2012
- A Client Profile Jan 1, 2010