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Medicare's Home Health Benefit

If you qualify, Medicare will cover your home health care. You are entitled to Medicare coverage of your home health care if you meet the following requirements:

  • You are confined to your home (meaning that leaving it to receive services would be a "considerable and taxing effort").
  • Your doctor has ordered home health services for you.
  • At least some elements of the services you receive are "skilled" (intermittent skilled nursing care, physical therapy or speech therapy).

If you need an element of "skilled" care, then you will also be entitled to Medicare coverage of social services, part-time or intermittent home health aide services, and necessary medical supplies and durable medical equipment. You can receive up to 35 hours of services a week, although few beneficiaries actually get this level of service. You are entitled to the same level of services whether you are a member of an HMO or are enrolled in traditional fee-for-service Medicare.

Medicare recipients do not have to pay anything for these services except 20 percent of the cost of medical supplies and equipment, which is covered by some Medigap policies.

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While under the law there's no limit on the length of time you will be covered, in practice coverage is limited. While the government insists that it has not changed the criteria for who is eligible for home care services, home health agencies have inevitably cut back on services they provide in order to make their own budgets balance. All this means that Medicare recipients must advocate for the services they need. Medicare home health benefits can mean the difference between you or a family member continuing to stay at home, or your health deteriorating until hospital care or nursing home placement become necessary.

If you have to appeal a termination of service, the good news is that most people who appeal Medicare home health benefits win their cases. At the first level of review, 39 percent are successful, and on appeal to an administrative law judge, 81 percent are successful. The bad news is that you have to pay privately for the care in order to have an appealable issue. This is because the issue on appeal is not the termination of a service, but the denial of Medicare payment for the service. As a result, many beneficiaries simply try to make do without the care or hire help on their own without the training and supervision provided by home health agencies.

Most Medicare beneficiaries are not informed of their appeal rights when given notice that their home health care benefits will be terminated. If your benefits or those of a family member are reduced or terminated, you should take the following steps:

  1. Ask your home health agency to explain the cutback and write down its answer. Ask the agency to give you written notice of the cutback or termination of service.
  2. Ask your physician to call the agency to urge it not to cut back the services and to provide a letter verifying the level of care you need. This can be essential to whether you ultimately receive the benefits you deserve.
  3. Consult your attorney or a Medicare assistance agency in your state to determine whether you likely would be successful on appeal.
  4. If you decide to appeal, do so immediately, and arrange with the home health agency to pay privately for the services pending the result of the appeal.

Medicare has typically cut off payment for home care services when the patient failed to improve, which is illegal.  Under the settlement of a lawsuit lodged in 2011, Medicare will no longer use this as a reason to discontinue or deny services, meaning that Medicare beneficiaries who need skilled care to maintain their current level of functioning or to avoid further deterioration should get continued coverage.   For details, click here

 


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