Medicare home health coverage can be a crucial resource for individuals with long-term or chronic conditions who continue to reside in their homes. Beneficiaries who meet the qualifying criteria are eligible for home health coverage if the skilled care provided is medically reasonable and necessary.
Medicare home health coverage is not just a short-term, acute care benefit. Unfortunately, unfair coverage denials still occur on the basis that the individual was not improving or did not demonstrate a potential for improvement (known as the “Improvement Standard”). Jimmo v. Sebelius, a nationwide class-action lawsuit, was brought on behalf of Medicare beneficiaries who received care in skilled nursing facilities, home health care, and outpatient therapy settings, but who were denied Medicare coverage based on this Improvement Standard. The Jimmo Settlement clarified that improvement is not required to obtain Medicare coverage.
The Center for Medicare Advocacy, with support from the John A. Hartford Foundation, is issuing this factsheet to outline Medicare home health coverage criteria in light of Jimmo v. Sebelius.