The Center for Medicare
Advocacy is pleased to share the following information based on questions
that were received from the January 12, 2022 webinar on Medicare coverage of
home health services. Recordings of that webinar and the follow-up session
are available at www.medicareadvocacy/webinars.
During the webinar we were
discussing “Medicare-certified home health agencies.” This means they have
been approved by Medicare to provide the home health services Medicare
covers, and they have agreed to be paid by Medicare. Medicare only pays for
home health services provided by Medicare-certified home health agencies.
Go to Medicare’s “Care Compare” website and
under “Provider Type,” select “Home health services,” to find Medicare-certified
home health agencies that serve your area. The doctor or other provider
ordering home health services may also have suggestions for home health
agencies. Discharge planners from hospitals and nursing facilities may also
be able to assist. If you are in a Medicare
Advantage plan (like an HMO or PPO) or another Medicare health plan (like a
Program of All-inclusive Care for the Elderly), it may require that you use
home health agencies that are in their network. It may be useful to contact
several different home health agencies that serve your area, if possible, as
there can be significant differences in the services they offer.
Medicare only covers home
health services that Medicare-certified home health agencies provide directly
or “under arrangement” with another provider that furnishes the services and
then looks to the primary home health agency for payment. The primary home
health agency must bill Medicare for all covered services, and payment is
made only to that agency. Thus, unlike many Medicaid or other state-based programs, in
which beneficiaries can hire family members as personal care attendants,
Medicare does not cover home health services in that manner. Nor does
Medicare reimburse patients for private-pay home health services. All Medicare
payments for home health services must go through a Medicare-certified home
health agency. The Center for Medicare
Advocacy issued a brief about Medicare and family caregivers in June 2020,
available here.
The Medicare home health
benefit can be used together with other benefit or insurance programs.
Exactly how depends on those programs’ individual rules. An example in
Section 50.7.1 of Chapter 7 of the Medicare Benefit Policy Manual
explains that if a patient requires more
skilled nursing/home health aides than the allowable “part-time or
intermittent” hours under the Medicare benefit, Medicare can cover its
maximum amount (35 hours per week of nursing and aides combined), with the
remainder billed to another payer. Inquire with the other programs to find
out how they can be combined with Medicare’s home health benefit. For assisted living facilities,
refer to Section 30.1.2 of Chapter 7 of the Medicare Benefit Policy Manual.
As described in that section, an assisted living facility can count as a
patient’s place of residence and patients can receive Medicare-covered home
health services there. But Medicare will not cover services that are
duplicative of services furnished by the facility.
Coverage does not depend on the
patient’s diagnosis or condition. It depends on whether the person meets
Medicare’s standard for coverage of home health services. An individual determination
must be made for each person. Some basic elements that must be met by the
patient include:
-and-
If the beneficiary meets the
above standards, then coverage of “dependent” services, including home health
aides, is also possible. See slides 5 through 16 of the
1/12/2022 webinar (emailed on 1/12/2022) for more details on Medicare’s
eligibility criteria. Note that the patient only needs to require one skilled
service to be eligible for coverage, including coverage of dependent services
like home health aides. In other words, it is not necessary to require both physical therapy and
skilled nursing, for example, to be eligible for coverage of home health
aides. Requiring either nursing or physical therapy would be a sufficient
basis to be eligible for aide services.
When both skilled nursing and
home health aide visits are provided, the two services combined cannot exceed
the “part-time or intermittent” hourly limits per week. The limits for
skilled nursing and home health aides combined are 28 or fewer hours per
week, and on a case-by-case basis up to 35 hours per week. The weekly hour
limits apply only to nursing and home health aide visits. Skilled nursing and
home health aide visits are not combined in this way with any other type of
service. So coverage of therapy visits is not affected by the number of
skilled nursing visits. Similarly, when home health aide and therapy services
are provided (with no skilled nursing ordered), the limit on home health aide
hours is not combined with therapy.
A person can meet Medicare’s
definition of “homebound” based on a mental, psychological, or other health
condition that does not affect their physical mobility. As with the need for
skilled care, an individualized determination must be made. The questions to
ask are whether the person requires the aid of a device or another person to
leave the residence, or whether the person has a condition that makes leaving
home medically contraindicated. There must also be a normal inability to
leave the home and it must require considerable taxing effort. (See slides
8-10 of the webinar for more detail on the homebound standard). The Medicare Benefit Policy Manual,
Chapter 7, Section 30.1.1 provides the following examples of patients who are considered homebound: “A patient who is blind or
senile and requires the assistance of another person in leaving their place of
residence.” “A patient with a psychiatric
illness that is manifested in part by a refusal to leave home or is of such a
nature that it would not be considered safe for the patient to leave home
unattended, even if they have no physical limitations.”
The Manual also explains that: “The aged person who does not
often travel from home because of frailty and insecurity brought on by
advanced age would not be considered confined to the home for purposes of
receiving home health services unless they meet one of the above conditions
[referring to the standards for being considered homebound].”
In April 2020, Medicare
clarified that the when a doctor has determined that it is medically
contraindicated for a beneficiary to leave the home because he or she has
confirmed or suspected case diagnosis of COVID-19, or , where a doctor has
determined that it is medically contraindicated to leave the home because the
patient has a condition that may make the patient more susceptible to
contracting COVID-19, those patients may be considered homebound. Medicare
also stated that a patient who is exercising “self-quarantine” for their own
safety would not be considered homebound unless a doctor certifies that it is
medically contraindicated for them to leave the home. Medicare also noted that under
CDC guidance about older adults and individuals with serious underlying
health conditions, it expected that many Medicare beneficiaries could be
considered homebound. It noted, however, that “determinations of whether home
health services are reasonable and necessary, including whether the patient
is homebound and needs skilled services, must be based on an assessment of
each beneficiary’s individual condition and care needs.” 85 Federal Register
19230, 19247 (April 6, 2020).
A basic difference is that
physical therapists focus on patients’ ability to move their bodies, while an
occupational therapist focuses on patients’ ability to perform activities of
daily living. Both services can be critical to either improving or
maintaining function, and the ability to remain at home.
That is incorrect. If a patient
requires skilled care (including services from a physical therapist) in order
to maintain their current function or to prevent or slow decline, Medicare
coverage is available as long as all other coverage criteria are met. This
coverage standard was clarified and reinforced by the settlement in Jimmo v. Sebelius. The
following is taken from Medicare’s Frequently Asked Questions page
about Jimmo: Q11: If
a patient is not improving or is not expected to return to his or her prior
level of function from skilled nursing or therapy, does Medicare coverage for
skilled nursing or skilled therapy services stop unless the patient
deteriorates? A11:
The Medicare program does not require a patient to decline before covering
medically necessary skilled nursing or skilled therapy. For a patient who had
been expected to improve, but is no longer improving, a determination as to
whether skilled care is needed to maintain the patient’s current condition or
prevent or slow further deterioration must be made, and if such skilled care
is needed, a plan of care to reflect the new maintenance goals must be
developed. If, however, a patient is no longer improving and there is no
expectation of improvement and skilled care is not needed to maintain the
patient’s current condition or to prevent or slow further deterioration, such
skilled care services would not be covered. Thus, if a patient is expected
to decline without skilled physical therapy, that should be explained in the
documentation and the plan of care should reflect maintenance of function or
prevention of decline as the goal of the plan. Medicare recently reminded
providers and its contractors about the availability of coverage to maintain
or to prevent or slow decline. See the Center for Medicare Advocacy’s Alert.
More information about Medicare
coverage of skilled nursing and therapy services to maintain function or to
prevent or slow decline or deterioration can be found on Medicare’s Jimmo Settlement webpage. The
page includes an “Important Message” about Jimmo,
as well as links to resources such as Frequently Asked Questions. The Center for Medicare
Advocacy’s website also has resources about maintenance
coverage and Jimmo,
including our own set of Frequently Asked Questions
and self-help materials for appeals
when denials are based on an inappropriate “Improvement Standard.”
Medicare Advantage plans must,
at a minimum, cover the same services as traditional Medicare (Parts A and
B), which includes the clarified standard for coverage of skilled care under
the Jimmo
settlement. Traditional Medicare does not
have deductibles or co-insurance payments for home health care, known as
patient cost-sharing. Each Medicare Advantage plan may impose different
cost-sharing amounts, including deductibles and co-insurance payments. If a
beneficiary is enrolled in Medicare Advantage they should confirm
cost-sharing requirements with their plan. As noted above, Medicare
Advantage plans may require that you receive home health services from an
in-network Medicare-certified home health agency. Medicare Advantage plans
may also require prior authorization of services, that is, the plans may
require that they approve the home health services before they are furnished,
even if your doctor has ordered them. Each plan has different requirements,
so people enrolled in Medicare Advantage plans should contact their plan to
ask if/when prior authorization is needed.
While there is no template for
home health orders, doctors and other practitioners who can order home health
services should keep in mind that the more specific they can be about the
services you need, the better. For example, if you require physical therapy
in order to maintain your current capabilities or to prevent decline, that
should be expressly stated as a goal. If one of the services you require is
home health aides, the doctor should specify which hands-on services you need
the aides for. This might include not only bathing or showering but also
toileting, assistance with medications that are normally self-administered,
changing position in bed, transfers, and walking. (See the Center for
Medicare Advocacy’s Fact Sheet on home health aides
for more details on the types of care home health aides may provide). Doctors and other practitioners
who order home health care may get most of their information about Medicare
coverage from home health agencies and may have misconceptions or
misunderstandings about what Medicare can cover. Materials from the webinar,
our website, and other resources
linked to in these questions and answers can be used to provide information
and education.
A doctor (or other authorized
practitioner) must order the home health services. Doctors should order what
they consider to be reasonable necessary home health services for the
individual patient, and they should be as specific as possible about what
services the patient needs. Generally staff from the home health agency will
come to the home to perform an assessment. The home health agency should work
with the patient and doctor to develop a plan of care. Home health agencies
must follow doctors’ orders and provide all services listed in the plan of
care. The reality is that home health
agencies sometimes have great influence over which services the doctor orders
and what is listed in the plan of care. This can be caused by many factors
including staffing constraints, financial incentives, and misconceptions
about what Medicare covers. Try to work closely with the ordering doctor and
provide information to the doctor and home health agency about Medicare
coverage rules if needed. Trying different home health agencies, if possible,
can be a useful strategy in advocating for the home health services you are
eligible for. See the question below about
appeals for certain situations when patients have the right to appeal to
Medicare about coverage.
As we discussed during the
webinar, there is often a large gap between the home health services Medicare
is authorized to cover by law versus the services beneficiaries can actually
access. There are many complex reasons for this, including Medicare’s home
health payment system and other policies like auditing and quality rating
systems. While the COVID-19 public health emergency has exacerbated the
situation, home health access problems are longstanding and pre-date the
pandemic. We encourage Medicare beneficiaries,
their family members, caretakers, and other helpers, to try advocating for
reasonable and necessary services that can be covered by Medicare. This may
mean educating home health agencies, doctors, and other providers, and
pushing back against misconceptions about the home health benefit. Discuss
the need for home health services with the ordering doctor to ensure the
necessary services are ordered and included in your plan of care. If the goal
of the services is to maintain your condition or to slow decline, ensure this
is stated in the order for services and plan of care. Use resources such as
Medicare’s official booklet for beneficiaries about home health (Medicare & Home Health Care);
Chapter 7 of the Medicare Benefit Policy Manual (Home Health Services)
(a Medicare publication geared more to providers); information about the Jimmo settlement, and other resources from our website;
and use Medicare’s appeal system when possible. Some local Legal Aid programs
offer assistance to people facing problems with their Medicare coverage,
particularly if an appeal is needed. Local Area Agencies on Aging
(AAAs) may also be able to help with coordination of services, including
screening for programs other than Medicare that provide services to help
people remain in their homes. While the Center for Medicare
Advocacy generally does not provide representation to individual
beneficiaries, we are interested in hearing your stories about Medicare and
home health services, and we may be able to provide information. Visit our
website, www.MedicareAdvocacy.org;
call (860) 456-7790; or email HomeHealthCare@MedicareAdvocacy.org.
Medicare has an appeal system
that can be used in certain situations. If you are receiving
Medicare-covered home health services and all services are ending, you may
have the right to an “expedited”
(fast)
appeal if you think the services are ending too soon. Your home health agency
is required to give you a written notice called a “Notice of Medicare
Non-Coverage” at least two days before all covered services end. Follow the
instructions on the notice carefully to request a fast appeal. To appeal you
will contact a certain type of Medicare contractor that looks at your case and
decides if Medicare coverage of your home health services should continue.
Expedited appeals can only be used if all services are ending, not if one
type of service (like physical therapy or home health aides) is ending but
other services are continuing. If you succeed in an expedited appeal,
services and coverage may continue. You have a right to pursue a standard appeal for
coverage of services you have received.
In these cases, the home health agency must give you a written notice called
an “Advance Beneficiary Notice of Noncoverage” (ABN) before giving you a home
health service or supply that the agency thinks Medicare won’t cover. This
may be because the home health agency thinks you are not homebound, thinks
the care is not reasonable and necessary for you, or thinks you do not
require any skilled service. To appeal to Medicare in this situation you need
to keep getting the service in question, which means you may have to pay the
home health agency for it. This is not affordable for many people, and the
Center for Medicare Advocacy has observed that home health agencies are often
reluctant to continue providing services they do not believe will be covered.
However, sometimes patients can pay for services for a short amount of time.
If the agency will
continue to provide services and you would like to appeal for Medicare
coverage of them, you should request that the home health agency send your
claim to Medicare so that Medicare will make a decision about coverage
(called a “demand bill”). When you receive an official denial of coverage
from Medicare, you have the right to appeal it by following the instructions
on the Medicare Summary Notice. Detailed information on
pursuing a home health expedited appeal is on the Center for Medicare
Advocacy’s website here and here. Information on the
difference between expedited and standard appeals is here. For people in Medicare
Advantage plans, the appeals process may be different from traditional
Medicare. Contact your plan for details. In any type of appeal the
doctor is the patient’s most important ally. Ask your doctor to help
demonstrate that the standards for Medicare coverage of home health care met.
In particular, ask the doctor to explain in writing why you are homebound (as
defined by Medicare) and why you require skilled care and other services that
are reasonable and necessary for you. At the Center, we would like to hear
from people who are trying to appeal for coverage of home health services,
whether it is expedited or standard. Please contact us at HomeHealthCare@MedicareAdvocacy.org
to let us know if you are trying to pursue an appeal to Medicare about your
home health services. |
|
|
Center for Medicare Advocacy, Inc. • www.MedicareAdvocacy.org • PO Box 350,
Willimantic, CT 06226 • 1025 CT Ave. NW, Washington, DC 20036 |
Tuesday, January 25, 2022
Home Health Webinar Q & A
Subscribe to:
Post Comments (Atom)
No comments:
Post a Comment