Case Study: Home Health Coverage and Medicare Advantage Plan Responsibilities

The Center for Medicare Advocacy received an e-mail inquiry from an individual requesting assistance advocating for her sister, Mrs. B.  Mrs. B is a Medicare beneficiary enrolled in a Medicare Advantage plan and in need of home health services.  The questions raised demonstrate several important issues that often arise with both the home health benefit as well as with someone who is enrolled in a Medicare Advantage plan.  This CMA Alert examines these real-world challenges in accessing the home health benefit, the law that requires coverage for these services, and advocacy tips to help maximize home care services.

Facts

Mrs. B is 68 years old with a primary diagnosis of Alzheimer’s disease.  Her condition is advanced to the point that she must live in a specialized residential setting where she receives care through music therapy and other methods of redirection.  Her Alzheimer’s disease causes unpredictable outbursts, agitation, screaming, and physical aggression.  Mrs. B’s behavioral issues make it impossible for her to do something as ordinary as leaving her home to visit the dentist.

Mrs. B is enrolled in a Medicare Advantage plan.  Her sister believes that she is in need of the services of a visiting nurse for medical attention including for general check-ups for her behavioral issues, mammograms (she is a two time breast cancer survivor), and blood draws.  However, the Medicare Advantage plan informed her that there is a rule that prohibits them from sending a visiting nurse to someone who does not live in a skilled nursing facility.  Mrs. B’s sister believes that a skilled nursing facility is not the appropriate setting for her sister, fearing that such a setting would upset her more and would not be able to meet her needs the way the specialized residential setting does.  Mrs. B pays a doctor privately to come and provide regular check-ups.

Mrs. B’s sister contacted the Center for Medicare Advocacy regarding the Medicare Advantage plan’s authority to refuse to provide a visiting nurse to someone who does not reside in a skilled nursing facility.  She also sought tips on how she could make it clear that her sister’s needs fall within the scope of Medicare’s rules for home health coverage.

Law

The Medicare home health benefit provides coverage for home visits by skilled health care professionals.  Medicare Advantage plans must provide all enrollees with all coverage included in Part A and Part B of traditional Medicare, including the home health benefit.  Medicare beneficiaries are entitled to the same level of coverage whether they are enrolled in traditional Medicare or a Medicare Advantage plan.  There is certainly no rule that coverage of home health services is conditional upon someone living in a skilled nursing facility (SNF).  In fact, home health coverage is not available for SNF residents.

In fact, Medicare beneficiaries are eligible for Medicare coverage of their home health care if they meet the following requirements:

  • They are confined to their home, “homebound,” per the Medicare Statute:

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 device (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 and 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 be an absence of infrequent or short duration.  42 USC §§ 1395f(a)(8) and 1395n(a)(2)(f).

  • They need 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).  Skilled care can also include skilled therapy services including physical, speech or occupational therapy services.  If they need skilled care then they may also be entitled to Medicare coverage of medical social services and part-time or intermittent home health aide services.
  • Their physician signs a plan of care including a home health certification.  A “face-to-face” meeting must take place as part of the certification.
  • They receive care from a Medicare-certified home health agency.

Analysis and Advocacy Tips

In Mrs. B’s case the Medicare Advantage plan believes that she is not homebound and also that she does not require skilled services.  Mrs. B’s sister should first clarify with the Medicare Advantage plan whether it is saying that Mrs. B does not qualify for home health coverage on either or both of these rationales.  As an enrollee of a Medicare Advantage plan, Mrs. B has appeal rights.  She has the right to insist on and receive a written decision when the Medicare Advantage plan refuses to cover certain services.  This decision can be appealed.

A strong argument exists that Mrs. B is homebound due to her Alzheimer’s disease.  The mental effects of her condition cause her to not even be able to leave home to go to the dentist.  Thus she meets the legal homebound criteria of normal inability to leave home and leaving home requiring a considerable and taxing effort.  She likely also needs extensive assistance of another person to leave home.  The Centers for Medicare & Medicaid Services (CMS) Policy Manual sets out examples of people who are homebound and factors that are used to determine whether a homebound condition exists.  One example that could help establish that Mrs. B meets the legal definition of homebound involves a person “with a psychiatric illness that is manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe for the patient to leave home unattended, even if they have no physical limitations.”  Medicare Benefit Policy Manual (MBPM) 100-02, Ch. 7, §30.1.1 (see full website below).

It also appears that Mrs. B needs skilled services.  The statute and regulations do not contain a detailed definition of the term “skilled care” for home health purposes.  This central term is thoroughly explained, however, in the regulations dealing with coverage for skilled nursing facility services and is incorporated by reference into the Medicare home health regulations.  42 C.F.R. §409.44(b).  The examples of skilled services include overall management and evaluation of the patient’s care plan, observation and assessment of the patient’s changing condition, patient education services, as well as specified skilled treatments.   The regulations specifically state that “[p]atients who, in addition to their physical problems, exhibit acute psychological symptoms such as depression, anxiety, or agitation, may also require skilled observation and assessment by technical or professional personnel to ensure their safety or the safety of others, that is, to observe for indications of suicidal or hostile behavior.”    42 C.F.R. §409.33(a)(2)(ii).

Based on her extreme behavioral issues it seems there is a reasonable potential for alteration in her condition which would necessitate a nurse coming in on a regular basis (i.e., at least once every 60 days) to provide skilled clinical observation and assessment and possibly to adjust her medication regimen.  Note, however, if her care need is primarily for venipuncture to obtain a blood sample, that is not considered to be skilled care according to Medicare.  MBPM 100-02, Ch. 7, §30.1.1 (see full website below).  It is not likely she needs a breast exam every 60 days, or that it would be reasonable and necessary every 60 days.  Also, traditional Medicare does not cover routine dental services, and Mrs. B’s Medicare Advantage plan does not cover dental services as a supplemental benefit.

Mrs. B’s sister should inform Mrs. B’s treating physician of what the Medicare Advantage plan is saying, and ask for his or her support.  The treating physician is the patient’s most important ally and should be the person who ultimately decides whether home health services are necessary.  She should ask if it is possible for the physician to order a psychiatric nurse to evaluate her sister at least every 60 days if her behavior could be a danger to herself or others, or if she needs counseling and possible monitoring/adjustment of her medications.  In addition, she should see if there are other medical conditions, even chronic ones such as diabetes or heart disease which might give Mrs. B problems and require monitoring or management.  Finally, she should discuss with the doctor whether Mrs. B is in need of skilled therapy such as physical therapy or speech therapy.  If the doctor believes that Mrs. B requires any of the skilled services listed above, Mrs. B’s sister should ask the doctor to complete a Home Health Certification and Plan of Care form, and also to contact the Medicare Advantage plan directly to explain the need for home health services.  If the Medicare Advantage plan continues to refuse to provide for or cover the home health services Mrs. B’s sister should exercise her right to appeal.

Conclusion

The Medicare home health benefit can be invaluable and can be available for beneficiaries in their homes, including in assisted living facilities.  Receiving medically necessary home health services can mean the difference between someone remaining safely at home, or risking the deterioration of their health to a point that they require nursing home placement or, worse, hospitalization.  Medicare coverage is available for necessary home care even if that care will extend over a long period of time.  There is no legal limit to the duration of the Medicare home health benefit.  This does not, however, mean that in practice there won’t be roadblocks and challenges to getting coverage.  It is important to know your rights and to be able to advocate for yourself or on behalf of another to optimize the chance of utilizing this valuable Medicare benefit.

You can visit the Center’s website, as well as the CMS website for further information about the home health benefit and Medicare Advantage appeal rights.

August 2015 – M. Ashkar