We’ve all seen it.
Neighbor A suffers a medical event, spends multiple days in the hospital and gets discharged to home. Medicare pays for a team of professionals to come out and care for Neighbor A in the home, including, for example, a licensed practical nurse, a physical therapist, a speech therapist, and an occupational therapist. Medicare also pays for home health aides who help with daily activities in the home including bathing and dressing.
Neighbor B, on the other hand, is simply getting older and more frail and needs more help with daily activities in the home. His children have jobs and can’t be with him all day. Neighbor B privately pays in full for home health aides to come out each day and help him in the home. Medicare pays for nothing toward the home health aides. Neighbor B’s assets are depleting rapidly. The family fears it might be time for Neighbor B move to an assisted living facility, at its exorbitant cost in independence, emotion, and money. Neighbor B and his family are distraught.
Why does Medicare pay for Neighbor A’s home care but not Neighbor B’s? It seems so unfair.
The Law: When and What Medicare Covers in the Home, and For How Long When Medicare Covers In-Home Care:
Under the Medicare Act, Medicare covers home health services under both Parts A and B of Medicare when:
1.The services are medically “reasonable and necessary”, which is a specialized definition linked to the service in question. For example, per 42 C.F.R. § 409.42(c)(1)(i): “In the home health setting, management and evaluation of a patient care plan is considered a reasonable and necessary skilled service when underlying conditions or complications are such that only a registered nurse can ensure that essential non-skilled care is achieving its purpose.”; and
2.The following 4 criteria are met:
a.Plan of Care. The physician or authorized provider must: (i) prescribe a plan of care for furnishing the services, and (ii) periodically review that plan of care to continue or discontinue the services. 42 C.F.R. § 409.43.
b.Homebound. The person is confined to home, commonly referred to as “homebound”. This does not mean the individual is unable to ever leave the home. The requirement is generally met if non-medical absences from home are infrequent, and leaving home requires a considerable and taxing effort. This can be shown by the patient needing personal assistance or the help of an assistive device such as a wheelchair or walker. The following should not bar a “homebound” finding: walks around the block, or attendance at an adult day care center, religious services, or a special occasion. 42 C.F.R. § 409.42.
c.Skilled Services Needed on Intermittent Basis.
The person must need care that is defined by Medicare as “skilled” (meaning (i) skilled nursing care, or (ii) physical or speech-language therapy) on an intermittent basis.
These “hooks” of skilled services are first required before occupational therapy and home health aides are available. Skilled nursing, physical therapy, and speech-language pathology services are defined as “qualifying skilled” services for the purpose of establishing eligibility for Medicare home health coverage. A person must initially require and receive one of these skilled services, in order to receive Medicare for “dependent services” (meaning dependent upon a skilled service being in place) which include: (i) home health aide, (ii) medical social worker, (iii) occupational therapy, and (iv) medical supplies.
For example, while occupational therapy is not considered a skilled service to begin Medicare home health coverage, if in addition to occupational therapy the person was receiving skilled nursing, or physical or speech therapy, but those skilled services end, Medicare will continue paying for the occupational therapy. 42 C.F.R. §§ 409.42, 409.44, 409.45.
d.The term “intermittent or part-time” means furnished any number of days per week, so long as they are provided: (i) less than 8 combined hours each day and (ii) 28 or fewer hours each week (or, subject to review on a case-by-case basis based on need, less than 8 hours each day and 35 or fewer hours per week).
e.Medicare-certified home health agency. The services must be furnished by, or under arrangement with, a Medicare-certified home health agency. 42 U.S.C. § 1395f(a)(2)(C) ; 42 C.F.R. §§409.42 et seq.
What Medicare Covers in the Home:
If the qualifying conditions above are satisfied, Medicare covers the following home health services:
1.Part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse;
2.Physical therapy, speech-language pathology, and occupational therapy;
3.Part-time or intermittent services of a home health aide (personal hands-on care), which include:
a.Bathing
b.Dressing
c.Grooming
d.Feeding
e.Toileting
42 C.F.R. § 409.45(b)(1)(i)-(v).
4.Medical social services; and
5.Medical supplies.
42 C.F.R. §§ 409.42, 409.44, 409.45, Medicare Beneficiary Policy Manual, Ch. 7, § 30.4.
How Long Medicare Covers In-Home Care
