Navigating Medicare is confusing at best, and the rules for home health care are not well understood. Here are some basics to get you started.
Receiving in-home services rather than remaining in a nursing home or rehab center makes so much sense for many seniors who would prefer to enjoy the comforts of their own home. But getting Medicare to pay for these services can be tricky.
Kiplinger’s article, “Medicare Rules for Home Health Care,” explains that Medicare does cover in-home services, including skilled nursing and physical therapy. If a patient is eligible, there's typically no charge and no limit on the length of time they can receive the benefit.
Patient advocates contend that the problem is that the eligibility requirements are often misunderstood by patients and providers. For example, Medicare's requirement that patients be homebound is often incorrectly interpreted as meaning that a person who occasionally leaves home isn’t eligible. This confusion over the rules results in some patients never seeking care because they think they won't qualify. Others are wrongfully denied care or see their services terminated prematurely, some critics say. There looks to be a great deal of subjectivity in some of the rules governing home health benefits, advocates claim.
To qualify for Medicare, you must require part-time skilled nursing, physical or occupational therapy, or speech-language pathology. These services have to be provided by a Medicare-certified home health agency and under a care plan established by your doctor. Finally, a doctor must certify that you're homebound, but this isn't as restrictive as many people think. Under Medicare's rules, your illness or injury must cause you to have trouble leaving your home without help—like using a walker or special transportation—or must make leaving home difficult and medically unadvisable because of your condition. Things like occasional religious services or health care visits don’t disqualify a person from being “homebound.” It doesn’t mean bedbound, and some Medicare Advantage plans waive the homebound requirement entirely.
Home health care should keep going as long as you are eligible. Some patients’ services have been terminated because their condition isn’t improving, but the rules don’t require this. Medicare beneficiaries filed a nationwide class action lawsuit in 2011 arguing that providers were inappropriately applying an improvement standard. That case settled in 2013 with the understanding that patients should be able to get care to maintain their condition or even slow their decline. However, the misperception persists.
There are a number of resources available to those whose home health care has been wrongfully denied or terminated prematurely. Every state has a State Health Insurance Assistance Program, and there is also an organization called The Center for Medicare Advocacy. Note that if a home health agency makes a decision to stop providing care, it is required to provide you with written notice that includes a reason for ending care and contact information for a Quality Improvement Organization—a group of health-quality experts who review appeals. You may also wish to speak with an attorney who specializes in this area who can assist you with navigating the confusing layers of Medicare.
Reference: Kiplinger’s (June 2016) “Medicare Rules for Home Health Care”