Medicare Coverage for Homecare

The Center for Medicare Advocacy won a landmark decision benefiting people on Medicare. A summary of the coverage determination for homecare is listed below with permission from the Center for Medicare Advocacy.

Medicare home health coverage can be an important resource for people with long-term and chronic conditions who need care at home. Contrary to common belief, Medicare home health coverage is not just a short-term, acute care benefit. In fact, under the law, Medicare beneficiaries who meet the qualifying criteria are eligible for home health coverage so long as skilled care is reasonable and necessary. There are six threshold requirements for Medicare home health coverage: 1. The beneficiary must be home-bound. This requirement means it is difficult, or contraindicated, for the individual to leave home alone, he/she does so infrequently, or for medical or certain other allowed purposes. The requirement does not mean that a beneficiary can never leave home, or that the beneficiary must be bed-bound; 2. The beneficiary must require skilled nursing care on an intermittent basis, physical therapy, speech language pathology services, or, in some instance, occupational therapy; 3. A physician, or a recognized non-physician health care professional, must have a face-to-face meeting with the beneficiary prior to certifying his/her need for home health care; 4. A physician must order the care to be provided by the home health agency, and sign and certify a “Plan of Care;” 5. A document about the face-to-face meeting, signed by a physician, must be included in the home health care certification; and 6. The home health agency must be a Medicare-certified provider. Unfortunately, home health agencies and Medicare Contractors, which make Medicare claim determinations, continue to deny Medicare home health coverage, and/or access to care, even for patients who meet these coverage criteria. Too often, beneficiaries are told Medicare will not cover skilled nursing or therapy services because they have “plateaued,” or are “chronic,” or “stable,” or lack potential for improvement. These denials, based on an erroneous “Improvement Standard,” without an inquiry into whether skilled care may be required to maintain or prevent deterioration of a patient’s condition, violate the Jimmo Settlement.