( THE FOLLOWING STUDY ARTICLE IS INTENDED FOR BASIC AWARENESS AND NOT FOR LEGAL ADVICE. IF THE READER SEEKS LEGAL ADVICE CONCERNING HIS OR HER PARTICULAR SITUATION, HE OR SHE SHOULD SEEK OUT AN ATTORNEY IN A LAWYER CLIENT RELATIONSHIP. )
THERE IS A VERY SIGNIFICANT AND POTENTIALLY CONTINUOUS HOME HEALTH SERVICES BENEFIT UNDER MEDICARE PART A .
A. Home health services are :
Part-time or intermittent skilled nursing care (other than solely venipuncture for the purposes of obtaining a blood sample); Part-time or intermittent home health aide services; physical therapy; Speech-language pathology; occupational therapy; medical social services; medical supplies (including catheters, catheter supplies, ostomy bags, supplies related to ostomy care, and a covered osteoporosis drug.., but excluding other drugs and biologicals; Durable medical equipment while under the plan of care established by physician; medical services provided by an intern or resident-in-training under an approved teaching program of the hospital in the case of an HHA which is affiliated or under common control with a hospital; and services at hospitals, skilled nursing facilities, or rehabilitation centers when they involve equipment too cumbersome to bring to the home.
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 Section 40 – Covered Services Under a Qualifying Home Health Plan of Care -Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 142, 04-15-11 citing (Rev. 1, 10-01-03) A3-3118, HHA-205
B. To Qualify For The Home Health Services Benefit
To qualify for the Medicare home health benefit, the patient must meet the following requirements:
1 Be confined to the home;
2 Under the care of a physician;
3 Receiving services under a plan of care established and periodically reviewed by a physician;
4 Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy.
“Intermittent” means skilled nursing care that is either provided or needed on fewer than 7 days each week or less than 8 hours of each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable). See Section 30 – Conditions Patient Must Meet to Qualify for Coverage of Home Health Services Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 142, 04-15-11 citing (Rev. 1, 10-01-03) A3-3118, HHA-205 (Rev. 1, 10-01-03) A3-3117, HHA-204, A-98-49
1. The Patient Needs To Be Confined To The Home
In order for a patient to be eligible to receive covered home health services, the law requires that a physician certify in all cases that the patient is confined to his/her home. An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. …Any other absence of an individual from the home shall not so disqualify an individual if the absence is of an infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration. It is expected that in most instances, absences from the home that occur will be for the purpose of receiving health care treatment. However, occasional absences from the home for nonmedical purposes, e.g., an occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral, graduation, or other infrequent or unique event would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home. Generally speaking, a patient will be considered to be homebound if they have a condition due to an illness or injury that restricts their ability to leave their place of residence except with the aid of: supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person; or if leaving home is medically contraindicated. See Section 30.1.1 – Patient Confined to the Home – Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 142, 04-15-11 citing (Rev. 1, 10-01-03) A3-3117.1.A, HHA-204.1.A, A-01-21
A. – The Patient’s Home Or Place of Residence
A patient’s residence is wherever he or she makes his or her home. This may be his or her own dwelling, an apartment, a relative’s home, a home for the aged, or some other type of institution. However, an institution may not be considered a patient’s residence if the institution is a hospital or a skilled nursing facility, as well as most nursing facilities under Medicaid. Thus, if a patient is in an institution or distinct part of an institution identified above, the patient is not entitled to have payment made for home health services since such an institution may not be considered their residence. When a patient remains in a participating skilled nursing facility following their discharge from active care, the facility may not be considered their residence for purposes of home health coverage. See Section 30.1.2 – Patient’s Place of Residence – Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 142, 04-15-11 citing(Rev. 1, 10-01-03) A3-3117.1.B, HHA-204.1.B.
C. The Home Health Services Benefit Is Potentially Continuous And The Patient’s Restorative Potential Is Not The Deciding Factor Concerning The Benefit
Medicare does not limit the number of continuous 60-day episode recertifications for beneficiaries who continue to be eligible for the home health benefit. See Section 30. 5.2 – Periodic Recertification – Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 142, 04-15-11 citing (Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11). The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed . Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. See 42 C.F.R. §409.32( c ) Criteria for skilled services and the need for skilled services.
THEREFORE, THERE IS A VERY SIGNIFICANT AND POTENTIALLY CONTINUOUS HOME HEALTH SERVICES BENEFIT UNDER MEDICARE PART A AVAILABLE TO PATIENTS WHO SIMPLY NEED SKILLED SERVICES TO PREVENT FURTHER DETERIORATION OR TO PRESERVE CURRENT CAPABILITIES.
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