The decision can be abrupt and arbitrary. A home health worker tells you, “Your husband (mom, dad, sister, brother) isn’t getting any better, we’ve done all we can do, and now we can’t continue services, because Medicare isn’t going to pay for it.”
According to a recent story by Judith Graham, a journalist for Kaiser Health News, abrupt terminations of home health therapy services are hitting families across the nation. The terminations are in response to a January 1, 2020 change in how Medicare pays for home health services. Some home health agencies are suggesting that Medicare no longer covers certain home health services. But please note: That is NOT the case.
Physical, occupational and speech therapy services for some patients, especially those who have long-term severe illnesses, are the services that have been impacted the most. Under a new Medicare reimbursement system, home health agencies now have a stronger financial incentive to treat patients who need short-term therapy after a stay in the hospital or rehabilitation facility. Payments under the new reimbursement system are higher for people who are discharged from an institution and have services provided within the first 30 days — and get lower after that.
The new payment system applies to traditional fee-for-service Medicare and not to Medicare Advantage plans which have their own system. If you are told that Medicare’s home health benefits have changed, don’t believe it. Coverage requirements haven’t changed, and Medicare beneficiaries are still entitled to the same type of home health services.
If a therapist or home health agency says that Medicare does not cover a service any longer, that’s a red flag because Medicare hasn’t changed benefits, or the qualifications to receive benefits, but only the payment structure. To be eligible for Medicare home health benefits you must meet all of the following conditions:
- You are homebound. This means you are unable to leave home without considerable effort and you require help doing so.
- You need skilled nursing services, and/or skilled therapy care on an intermittent basis.
- You have a face-to-face meeting with a doctor within 90 days before starting home healthcare, or 30 days after the first day you receive care.
- Your doctor signs a home health care certification, confirming that you are homebound and need intermittent skilled care. The certification also must state that your doctor as approved a plan of care for you and that the face to face meeting requirement was met.
- You receive care from a Medicare-certified home health agency (not all home health agencies are).
If you have questions or experience billing issues, contact an advocate such as your doctor, and your area agency on aging. Multiple home health agencies operate in many areas of the country, and you may be able to find services through a different agency. For information on where to find help in your area, check the Eldercare Locator 1-800-677-1116.
Source: “Why Home Health Care is Suddenly Harder To Come By For Medicare Patients,” Judith Graham, Kaiser Health News, February 3, 2020.