Medicare home health coverage can be vital for seniors who are recently sent home from the hospital or who are suffering from a chronic condition and have trouble leaving home. Even so, taking advantage of this benefit can be a real challenge.
Kiplinger’s recent article, “Medicare Rules for Home Health Care,” explains that Medicare covers 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.
If a person believes his or her home health care is being wrongfully denied or ended prematurely, this individual can file an appeal. When a home health agency suspends care, it must provide written notice that includes the rationale for ending care and contact information for a Quality Improvement Organization, a group of health-quality experts who will review your appeal.
Reference: Kiplinger’s (June 2016) “Medicare Rules for Home Health Care”