Case Spotlight: A Medicare Beneficiary in Need of Home Health Aides

The Problem
Mrs. B contacted the Center for Medicare Advocacy seeking assistance with Medicare home health coverage. She lives with her husband who has advanced Parkinson’s disease. He receives physical therapy and speech language pathology through a Medicare-certified home health agency, but the agency told Mr. and Mrs. B they are “over Medicare’s income limit for a home health aide,” so they are paying the agency privately for a home health aide, 24 hours a week. Although Mrs. B is past full retirement age, and would like to retire, she works to support the private payments for her husband’s home health aide. The aide helps Mr. B get in and out of bed, does his grooming, helps him to eat and take medications, and takes him to the porch where he can enjoy the sunshine. The aide also sweeps the floor of his room and takes him to the doctor.
Analysis and Guidance from the Center for Medicare Advocacy

1. B is homebound and receives Medicare-covered skilled therapy. Under the law, this makes him eligible for necessary personal hands-on care from a home health aide for up to 28 hours a week (35 hours a week if specifically documented by his doctor). There are no income limits in Medicare – everyone who receives Medicare is eligible for the same benefit coverage. The B’s should not have to pay privately for a home health aide for Mr. B’s personal hands-on care for up to the hours coverable under the law.
2. Federal Regulations define the kinds of personal hands-on care from a home health aide that are coverable by Medicare (42 CFR 409.45(b)(1)(i)-(v); see definitions, below). The services include getting Mr. B in and out of bed, grooming, assistance with eating and taking medications, and helping to get to another area of the house. While sweeping the floor of his room is not directly hands-on personal care, Medicare allows for such services “incident” to personal care. When Mr. B moves barefoot from his bed to the bathroom, crossing a clean floor is important and, therefore, sweeping his bedroom floor, which takes little time, can be included as part of the home health aide services. On the other hand, driving Mr. B to his doctor is not a coverable service, since Medicare-covered aide services are limited to hands-on care performed in the home. Mr. B will need to make private arrangements for the transportation.
3. The Bs should contact Mr. B’s doctor to make sure the services provided by a home health aide have been ordered by the physician and are included in Mr. B’s Plan of Care. The physician can be very specific about the reason for the services and the best time of day to provide the care. Realistically, however, the Bs may need to be flexible in order to work with the agency regarding the hours of the day when the aide is available.
4. All home health services must be organized through a single Medicare-certified home health agency. However, if that agency cannot provide all the required services, it can make “arrangements” for the services it cannot provide with another agency. All Medicare payments must go to the original agency which must share them with the other agency as appropriate.  In practice, when home health agencies decline to provide home health aide services, they usually will not arrange with another agency to provide them. If Mr. B’s current agency cannot (or will not) provide Medicare-covered home health aide care, and if the Bs are not attached to that particular agency (because of Mr. B’s physical therapist and speech language pathologist, for example), they might want to seek services from another Medicare-certified home health agency that serves their zip code. They can find information on other available agencies by inserting their zip code at: https://www.medicare.gov/homehealthcompare/search.html
5. The official Medicare publication describing home health services may be helpful to support a conversation with a home health agency, home health aides are referenced on pages 8 and 9: https://www.medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf.
6. There is also a great deal of information about Medicare home health coverage on the Center for Medicare Advocacy’s website, MedicareAdvocacy.org.

References:
A. The Medicare Act includes personal hands-on care provided by home health aides as a Medicare covered service for individuals who are homebound and need and receive skilled nursing or therapy: 42 USC §1395x(m)(1)-(4)
B. Federal Regulations: 42 CFR §409.45(b), defines Home Health Aide Services as follows:
Home health aide services. To be covered, home health aide services must meet each of the following requirements:
(1) The reason for the visits by the home health aide must be to provide hands-on personal care to the beneficiary or services that are needed to maintain the beneficiary's health or to facilitate treatment of the beneficiary's illness or injury. The physician's order must indicate the frequency of the home health aide services required by the beneficiary. These services may include but are not limited to:
     (i) Personal care services such as bathing, dressing, grooming, caring for hair, nail and oral hygiene that are needed to facilitate treatment or to prevent deterioration of the beneficiary's health, changing the bed linens of an incontinent beneficiary, shaving, deodorant application, skin care with lotions and/or powder, foot care, ear care, feeding, assistance with elimination (including enemas unless the skills of a licensed nurse are required due to the beneficiary's condition, routine catheter care, and routine colostomy care), assistance with ambulation, changing position in bed, and assistance with transfers.
     (ii) Simple dressing changes that do not require the skills of a licensed nurse.
     (iii) Assistance with medications that are ordinarily self-administered and that do not require the skills of a licensed nurse to be provided safely and effectively.
     (iv) Assistance with activities that are directly supportive of skilled therapy services but do not require the skills of a therapist to be safely and effectively performed, such as routine maintenance exercises and repetitive practice of functional communication skills to support speech-language pathology services.
     (v) Routine care of prosthetic and orthotic devices.

(2) The services to be provided by the home health aide must be -

     (i) Ordered by a physician in the plan of care; and
     (ii) Provided by the home health aide on a part-time or intermittent basis.

(3) The services provided by the home health aide must be reasonable and necessary. To be considered reasonable and necessary, the services must -

     (i) Meet the requirement for home health aide services in paragraph (b)(1) of this section;
     (ii) Be of a type the beneficiary cannot perform for himself or herself; and
     (iii) Be of a type that there is no able or willing caregiver to provide, or, if there is a potential caregiver, the beneficiary is unwilling to use the services of that individual.
(4) The home health aide also may perform services incidental to a visit that was for the provision of care as described in paragraphs (b)(3)(i) through (iii) of this section. For example, these incidental services may include changing bed linens, personal laundry, or preparing a light meal.
C. Medicare Benefit Policy Manual, Chapter 7, Section 40 - Covered Services Under a Qualifying Home Health Plan of Care (Rev. 1, 10-01-03) A3-3118, HHA-205, Authorizes Medicare Coverage of Home Health Aide, as follows:
Section 1861(m) of the Act governs the Medicare home health services that may be provided to eligible beneficiaries by or under arrangements made by a participating home health agency (HHA). Section 1861(m) describes home health services as…
...The term "part-time or intermittent" for purposes of coverage under §1861(m) of the Act means skilled nursing and home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week). See §50.7.
For any home health services to be covered by Medicare, the patient must meet the qualifying criteria as specified in §30, including having a need for skilled nursing care on an intermittent basis, physical therapy, speech-language pathology services, or a continuing need for occupational therapy as defined in this section.