MEDICAID HOME HEALTH AIDE

For the thousands of individuals in our society struggling to live independently in the community, the Medicare home health benefit is a crucial funding source for health care finance. When monitored and with proper advocacy, Medicare’s home health benefit can provide necessary services to individuals who suffer from chronic conditions, even if the services are provided over an extended time period.

Under Medicare, the term “home health services” includes (1) part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse; (2) physical, occupational, or speech therapy; (3) medical social services under the direction of a physician; and (4) part-time or intermittent services of a home health aide. Medicare provides coverage for home health services under both Medicare Parts A and B. Coverage under Part A is limited to 100 visits and requires a prior stay in a hospital or skilled nursing facility.

In order to be covered, the services must be medically reasonable and necessary and the patient must meet several coverage criteria. Those criteria are as follows: (1) the patient must be confined to his or her home, this is known as the “homebound” rule; (2) the patient must require skilled nursing care on an intermittent basis, or physical or speech therapy; (3) a physician must establish and periodically review a plan regarding the provision of home health services; and (4) the services must be furnished to the patient by or under arrangement with a Medicare certified home health agency.

In 1997, Congress passed the Balanced Budget Act of 1997 (BBA ’97). BBA ’97 added several new criteria for coverage and caused a tremendous amount of confusion as to what services would be covered. As a result, many patients were incorrectly terminated or denied services under the home health care provisions. The confusion that the BBA ’97 has caused heightened the need for advocacy on behalf of the Medicare patient, in order to ensure that they receive this important level of care.

For those individuals seeking coverage of home health services under Medicare Part A, BBA ’97 added a prior institutionalization requirement, established a “home health spell of illness” benefit period, and created a 100-visit coverage limitation per spell of illness. For individuals seeking home health care coverage who fail to meet the prior institutionalization criterion or who surpass the 100-visit limit, coverage is available under Medicare Part B, if the patient is enrolled in both Parts A and B. The prior institutionalization rule and 100-visit limitation do not apply at all for individuals enrolled in only Parts A or B.

Proper advocacy on behalf of the patient incorrectly denied or terminated from home health services demands a thorough understanding of the criteria for coverage. Confusion as to the meaning of the prerequisites for coverage leads to improper denial of coverage; the criteria most frequently misunderstood are discussed below.

The “homebound” rule: An individual is considered to be “homebound,” if the individual has a condition, due to illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another or the aid of a supportive device (such as crutches, a cane, a wheelchair, or a walker), or if the individual has a condition such that leaving his or her home is contraindicated. Oftentimes, patients are denied home health care coverage because a determination has been made that the patient is not homebound. Misunderstandings as to the term “homebound” frequently create a problem for patients seeking home health coverage and who attend adult day care centers; however, contrary to popular misconception, Medicare home health services can be available to patients who attend adult day care centers.

The second principal criterion for home health services is the requirement that the patient need skilled nursing care on a part-time or intermittent basis. Often, the patient will require too much skilled care, exceeding the intermittent level of care, or will require no skilled care. Skilled nursing services are those of a registered nurse or a licensed practical nurse under the supervision of a registered nurse, necessary to treat the illness of a patient.

“Part-time or intermittent services” are defined as skilled nursing and home health aide services furnished any number of days per week as long as they are furnished less than 8 hours each day and 28 or fewer hours each week. “Intermittent” is further defined as skilled nursing care that is either provided or needed on fewer than 7 days each week, or less than 8 hours each day for periods of 21 days or less.

Once a patient has established that he or she is homebound and requires skilled nursing care on an intermittent basis, home health coverage under Medicare is available for therapy and for part-time or intermittent services of a home health aid or nurse. Current law and the Medicare guidelines provide that coverage may be available for up to 28 hours of aide and nurse services combined each week, without the necessity of special documentation.