Home health care can be covered by Medicare if it meets the following criteria:
- The patient must see a physician or authorized health care provider. The physician/provider must write a brief narrative describing the patient’s clinical condition and how the patient’s condition supports homebound status and the need for skilled home health services.
- A physician/authorized provider has signed or will sign a plan of care
- The patient is homebound. This standard is met if 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, or other supportive device. Occasional but infrequent “walks around the block” and outings are allowable. Attendance at an adult day center or religious services is not an automatic bar to meeting the homebound requirement.
- The patient needs skilled nursing care on an intermittent basis (at least once every 60 days), or physical or speech-language pathology. (Occupational therapy can continue Medicare home health care but not begin coverage.)
- The care must be provided by, or under arrangements with, a Medicare-certified provider.
Medicare Coverable Home Health Services
If the triggering conditions described above are met, the beneficiary is eligible for Medicare coverage of home health services. Generally, there is no deductible or coinsurance. (Check Medicare Advantage plans – some MA plans may include cost-sharing.)
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 under the direction of a physician, and;
- Part-time or intermittent Home health Aide services, to the extent permitted in regulations.
Other Important Points:
- Medicare coverage should not be denied simply because the patient’s condition is “chronic,” “stable,” or unlikely to improve. “Restorative potential” is not necessary. Medicare coverage is available to maintain an individual’s condition or slow deterioration.
- Resist arbitrary caps on coverage imposed by the Medicare contractor or insurer. For example, do not accept provider assertions that aide services in excess of one visit per day/week 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 necessary home care so long as coverage criteria are met – even if it extends over a long period of time.
- The doctor and other health care providers are the patient’s most important ally. If it appears Medicare coverage will be denied, ask them to provide information to help demonstrate that the standards above are met.
- Prior to the discontinuance of Medicare covered services the home health agency must issue a written notice of non-coverage. If you disagree with the discharge, pursue an appeal as soon possible, as directed in the notice.
January 24, 2024