Medicare Rules for Home Health Care

Medicare home health coverage can be a crucial benefit for seniors who have just been discharged from the hospital or who struggle with a chronic condition and have difficulty leaving home. But taking advantage of this benefit can be a real challenge.

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Medicare covers in-home services, including skilled nursing and physical therapy. For eligible patients, there's generally no charge and no limit on how long they can receive the benefit.

The problem, patient advocates say, is that the eligibility requirements are often misunderstood both by patients and providers. Medicare's requirement that patients be homebound, for example, is sometimes wrongly interpreted as meaning that an individual who occasionally leaves home can't qualify.

Confusion over the rules means that some patients never seek care because they mistakenly believe they won't qualify - while others are wrongfully denied care or see their services terminated prematurely, critics say. "There's a lot of subjectivity in some of the rules" governing home health benefits, says Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group.

About 3.5 million people received Medicare home health services in 2014, according to the Centers for Medicare and Medicaid Services. To qualify, you must need part-time skilled nursing, physical or occupational therapy, or speech-language pathology. The services must be provided by a Medicare-certified home health agency, under a care plan established by your doctor. To find Medicare-certified agencies in your area, go to medicare.gov/homehealthcompare.

The final requirement: A doctor must certify that you're homebound. But this isn't as restrictive as many people assume. To be homebound under Medicare's rules, your illness or injury must cause you to have trouble leaving your home without help, such as using a walker or special transportation, or leaving home must be difficult and medically unadvisable because of your condition. Occasionally attending religious serv-ices, visiting the doctor's office or going to adult day care doesn't mean that you can't qualify as homebound. Sometimes people think homebound means they have to be bedbound. Not true, says Melissa Simpson, senior program manager at the National Council on Aging's Center for Benefits Access. Some Medicare Advantage plans waive the homebound requirement altogether.

What to Do If You Are Denied

Your home health care should continue as long as you meet the eligibility requirements. In some cases, patients services are cut off because their condition is not improving. But the rules have never demanded that a patient's condition improve, says Diane Omdahl, president of 65 Incorporated, a firm that helps seniors navigate Medicare. In 2011, Medicare beneficiaries filed a nationwide class action lawsuit claiming that providers were inappropriately applying an improvement standard and the 2013 settlement of that case clarified that patients should be able to get care to maintain their condition or even slow their decline. Yet the misperception persists, says Michael Benvenuto, director of the elder-law project at Vermont Legal Aid, which represented the plaintiffs in the case.

If you think your home health care is being wrongfully denied or cut off prematurely, you can file an appeal. When a home health agency suspends care, it should give you a written notice that includes the rationale for ending care and contact information for a Quality Improvement Organization, the group of health-quality experts that will review your appeal.

You can get free help with your appeal - or simply with navigating the home health care benefit - by contacting your State Health Insurance Assistance Program (find your state's program at www.shiptacenter.org ). The Center for Medicare Advocacy offers detailed instructions for appealing home health care denials.