Medicare Home Health Coverage: You don’t have to improve to qualify for Medicare coverage!

Medicare’s coverage allows homebound people to get the necessary care and therapy they need. Unfortunately, this level of care has been very difficult to obtain in reality.

 

The Problem:

Medicare home health coverage can be a robust resource to help people who qualify remain at home with the necessary care. However, in recent years, coverage and access to home health care have been shrinking. The Centers for Medicare & Medicaid Services (CMS) regularly describes Medicare home health coverage as a short-term, acute care benefit. This is not true. As a result of this CMS perspective, however, which is reflected in Medicare home health payment and quality models, even people who meet the law’s coverage criteria (homebound and needing skilled nursing and/or therapy), are denied coverage and access to needed care. Further, qualified beneficiaries are only able to access the bare minimum of home health aides – often only 1-3 hours, for a bath, not 28-35 hours combined with nursing, for an array of personal care, as authorized by the law.

Background:

Medicare covers certain care provided at home for people who are homebound, as defined by the law, and who need and receive skilled nursing and/or therapy. The skilled services can be provided to improve or maintain or slow the decline of an individual’s condition. Individuals who meet these criteria are eligible for coverage of skilled nursing and/or therapy as well as for home health aides, medical social worker care, and some supplies. Under the law, the care can continue indefinitely, so long as the coverage criteria are met, including for up to 28- 35 hours of nursing and home health aides combined. Unfortunately, in practice, this level of care is often difficult to obtain.

 

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Case Studies:

Ms. W contacted us on behalf of her husband who has ALS and has been receiving Medicare-covered physical therapy at home as well as home health aide services. As a result of the physical therapy, his pain has been significantly reduced, he is able to transfer independently, and his bowel function has improved. Nonetheless, the home health agency told Mr. R that it was ending his home health care as he was not improving and no longer needed skilled physical therapy. My Elder appealed and the issues were resolved.

Ms. D contacted us because her mother who is 94 years old with multiple comorbidities, was told orally that her care was going to end because she wasn’t improving. She did not receive written notice. The proposed discharge was for the nursing, Physical Therapy, and Occupational Therapy that her doctor ordered to maintain her skin integrity and help her continue to be able to transfer out of bed into her wheelchair, ambulate a bit with a walker, and maintain the ability to perform activities of daily living as independently as possible. My Elder appealed and the issues were resolved.

Additional Information About JIMMO SETTLEMENT

In essence, the Jimmo Settlement Agreement clarifies Medicare’s longstanding policy that coverage of skilled nursing and skilled therapy services in the Skilled Nursing Facility (SNF), Home Health (HH), and Outpatient Therapy (OPT) settings does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.

For ready reference, this CMS web page serves to provide access, in one location, to various public documents related to the Jimmo Settlement Agreement. Included in those public documents is a FAQ document for easy access. The Jimmo Settlement Agreement does not alter or supersede any other applicable coverage requirements beyond those involving the need for skilled care, such as Medicare’s overall requirement that covered services must be reasonable and necessary to diagnose or treat the beneficiary’s condition, or existing statutory limitations on the amount or duration of Medicare benefits.

My Elder provides elder advocacy services to families. Talk to us about long-term planning, finding the right home for your loved ones, preventing crisis and abuse, and ensuring they receive the best care possible.

Photo Credits Julie Johnson