Medicare Covers In-Home Care.
Many people assume that Medicare provides little to no continuing coverage for in-home health care. In fact, the program covers up to 35 hours a week of nursing and home health care for those who meet specific requirements.
While patients with chronic conditions are frequently denied coverage, consumer advocates say it may be possible to prevail by pursuing appeals.
In order to secure coverage for home health care, Medicare first requires a patient to be homebound. That doesn’t equate to being bed-bound, says Judith Stein, founder of the nonprofit Center for Medicare Advocacy. Rather, such individuals typically need help moving about from a device (like a wheelchair) or a person.
A doctor also must approve a “plan of care” that includes the services of a nurse or physical or speech therapist. (In addition, the plan can include the services of an occupational therapist and a home health aide to assist with so-called “activities of daily living,” such as bathing, eating and dressing.) The doctor must renew the “plan of care” once every 60 days, says Kim Glaun, senior education and policy counsel at the nonprofit Medicare Rights Center.
The patient must contract with a home health agency that is certified by Medicare. A hospitalization isn’t a prerequisite for coverage, Ms. Stein says.
A nurse or therapist can come to a patient’s home as often as daily or as infrequently as once every 60 days. But when nursing care occurs daily, Medicare will cover it only if there is “a predictable end to the need” for daily care, according to the Center for Medicare Advocacy.
Be aware that home health agencies aren’t obligated to provide services to every patient. They turn away those they feel aren’t in compliance with Medicare’s requirements. Often, agencies are reluctant to take on patients with chronic conditions, such as Alzheimer’s and Parkinson’s disease.
In such instances, they may cite the notion that only patients with conditions that are likely to improve can qualify for coverage, says Ms. Stein, who argues the so-called “improvement standard” isn’t sanctioned under the law.
The Center for Medicare Advocacy recently filed a lawsuit in federal district court in Vermont that addresses this issue.
“There is absolutely no reason why someone with a chronic condition who is homebound and needs skilled care cannot get home care for a long period of time, which is why we brought this lawsuit,” Ms. Stein says. “It’s a big issue.”
If you are unable to secure coverage from a home health agency, you can search for another agency. You also can pay out-of-pocket for services and request in writing that the agency submit the bill to Medicare. If Medicare approves your claim, you’ll get reimbursed.
If not, you can appeal.