Little Known Medicare Benefits

Many people know that Medicare will pay for rehabilitation services in a nursing home if the patient has had a three day inpatient admission to a hospital. A physician must order the care in a nursing home and it must be related to the condition that resulted in the hospital services. Practically speaking, the care must only be available on an inpatient basis. The person must need to receive seven days a week of nursing home care, or skilled therapy five days a week or some combination seven days a week. This is the normal rehabilitation families know about. It cannot go more than 100 days, and normally is cut off sooner. For many years Medicare and nursing homes cut off rehabilitation paid by Medicare if the patient was not improving or had “plateaued”. In 2013, a federal court in the Jimmo case ordered the Medicare system to pay for care if it was needed to improve, maintain, or slow the decline of the patient. Getting better or improving, is not the test.

Because of the Jimmo case, Medicare home health coverage can be a vital resource for people with chronic and long-term condition, such as Parkinson’s, ALS, MS or paralysis. The important thing to remember is that the Medicare coverage is not just for a short-term acute care benefit in a nursing home. If a Medicare beneficiary meets the six qualifying criteria, coverage for care can last as long as skilled care is reasonable and necessary.

The six requirements for Medicare home health coverage are: 1. The applicant is homebound which means it is difficult to leave home alone and does so infrequently such as for medical reasons. It does not mean the person can never leave home or be bedbound. 2. Skilled nursing care must be required on an intermittent basis, for physical therapy, speech language pathology services, and possibly occupational therapy. 3. A doctor or non-doctor heath care professional must meet with the applicant before certifying the need for care. 4. The doctor must order the care be provided by a home health agency and certify a “Plan of Care”. 5. The doctor must sign a document about the meeting and include that in the home health care certification. 6. The home health agency must be a Medicare certified provider.

Despite the Jimmo case, many Medicare contractors and home health agencies still deny Medicare home health care coverage saying the patient is “chronic care” or “stable”, or has “plateaued” and lacks potential for improvement. The true test is whether the skilled care is needed to maintain or prevent deterioration of the patient’s condition. Most nursing homes now know the standard for inpatient care, but that is less known or followed for home care.

What can families do to increase chances they can get these Medicare Part B benefits? First, discuss with the patient’s doctor whether the doctor will certify a plan of care. An order for care is pretty much the equivalent of a certification. Don’t accept a denial stating the patient has plateaued, or has a chronic condition, or is stable. That violates the Medicare rules and the words in the Jimmo case that say the test is whether skilled care is required to “maintain or prevent deterioration” of the patient’s condition.

In Connecticut we are fortunate to have the Center for Medicare Advocacy which was a key player in the court case, and a tremendous source of information on what and when Medicare is required by law to provide services. In short, if your family member needs care at home to maintain their best level of functioning or to slow a chronic condition from deteriorating, question the doctor and rehabilitation staff if in home care could be available to help keep dad or mom at home for as long as possible. Medicaid may not be the only government benefit available. For more information you could visit the Center for Medicare Advocacy website and find New Issue Brief: Implementing Jimmo v. Sebelius: An Overview June 2019, from which much of this article was derived.