Medicare Home Health Services: Are Beneficiaries Receiving Adequate Care?

There has been a significant increase in the number of home health beneficiaries who have had benefits reduced or terminated by Medicare.  Home health agencies have told their patients that the changes are due to "the new law" or "the new caps" or that their care is too costly for the agency.

The Balanced Budget Act of 1997, signed into law on August 5, 1997, did make significant changes to the Medicare program and to the home health care reimbursement system.  However, it did not change the substantive medicare coverage criteria.  This report reviews the criteria for qualifying for Medicare home health benefits, describe what home health benefits cover and discuss remedies available to advocates who assist clients in obtaining their maximum benefits, thereby enabling them to fulfill their goal of living in their own homes.  

In order to quality for Medicare home health services, beneficiaries must meet the following criteria:

1.  A physician has signed a care plan.

2.  The patient is homebound.

3.  The patient needs skilled nursing care on an intermittent basis or physical or speech therapy.

4.  The care must be provided by a Medicare-certified provider.

Medicare regulations define a patient as homebound if leaving home requires a considerable and taxing effort, the assistance of another person or an assistive device, such as a wheelchair or walker.  A person need not be bedbound to be considered homebound.  Infrequent "walks around the block" are allowable.

Skilled nursing care must be needed and received at least once every 60 days.  Generally, the services must not be daily unless it can be shown that it will not be needed indefinitely.  In most cases, daily skilled nursing care will not be covered for more than 21 consecutive days.  However, Federal Regulation Section 409.32(c) specifically states that the restoration potential of a patient is not the deciding factor in determining whether skilled services are needed.  Even if full recovery or medical improvement is not possible, a patient may need skilled nursing services to prevent further deterioration or preserve current capabilities.

Once a patient meets each of the above requirements, they are entitled to Medicare coverage for home health services.  It is important to note that there is no co-insurance or deductible for these expenses.  These services include:

1.  Part-time or intermittent nursing care provided by a registered professional nurse.

2.  Physical, occupational, or speech therapy.

3.  Medical social services under the direction of a physician.

4.  Part-time or intermittent services of a home health aide.

 

Joel M. Sachs

Certified Public Accountant

Certified Senior Advisor

Konowitz, Kahn & Company, P.C.
 
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