Home health care can be the crutch that allows a struggling Medicare beneficiary to live independently in the community. However, this very important benefit may be unfairly denied. When you want to receive Medicare home health services, you must first approach a certified home health agency and request service. Typically, the agency will evaluate you and make a determination whether coverage will be available for the needed care. The Medicare home health benefit is covered under Part A and Part B of your Medicare insurance. When should Medicare coverage for home health be available?

The law states that Medicare covered home health services are available when the services are medically reasonable and necessary and when:

1. You are confined to your home or homebound;
2. You need skilled nursing care on an intermittent basis, or you need physical or speech therapy, or you have been receiving home care but you no longer need nursing care or therapy but you still need occupational therapy;
3. Your doctor has prepared a plan of care and is reviewing it periodically;
4. Medicare certifies your home health service agency.

You are homebound if leaving your home requires a considerable and taxing effort. Homebound does not mean that you may never go out. If you just occasionally walk around the block or go to the grocery store with assistance, that will not disqualify you. It does means that you require personal assistance, a wheelchair, a walker, a cane, or crutches to get where you want to go. However, physical limitations are not the only conditions that meet the homebound definition. A person who has Alzheimer's or a psychiatric problem if the illness results in the beneficiary not being able to leave the home either because of fear or safety concerns.

You need skilled nursing care if your care requires a registered nurse or licensed practical nurse (supervised by a registered nurse) perform some aspect of your care. Skilled nursing services might include overall management and evaluation of your care plan. Observation and assessment of your changing condition. The education services that you need to function with your condition. It also includes, but is not limited to, the specific skilled treatments such as injections, irrigation, tube feeding, suctioning, wound care, and tracheotomy care.

Skilled nursing care is one of the areas that frequently result in the denial of home health services. You should not just accept the denial when you receive your notice. The Medicare Home Health Agency Manual provides many examples of what should be deemed skilled care which may be ignored when the denial decision is made. For example, the administration of insulin to a diabetic is a skilled service, even when it is taught to a family member. Observation and assessment of a patient's condition is a skilled nursing service when the likelihood that a change in the patient's condition would require a skilled nurse to identify and recognize the change. A nurse's evaluation of a family's care-giving efforts is skilled nursing care.

Your diagnosis should never be the sole factor in deciding that the service required is either skilled or non-skilled. The determination should be based solely on your condition and your individual needs. Coverage should not be denied simply because your condition is "chronic" or "stable."

There is no limit to the duration of Medicare home health benefit. Medicare coverage is available for necessary home care even for extended periods of time. Also, caps on coverage may not be appropriate. The service may be provided on a "part-time or intermittent" basis. That may mean that you can receive home service any number of days per week as long as the service is furnished less than eight hours per day and twenty-eight or fewer hours per week. It also means that skilled nursing care that is provided on fewer than seven days each week, or less than eight hours of each day for a periods of twenty-one days or less is covered. Using the definitions of "part-time or intermittent" means that you should be able to obtain coverage for home health services seven days a week, but less than eight hours per day, or six or fewer times per week for as many as twenty-four hours per day.

Your doctor is your most important ally in obtaining and keeping Medicare home health benefits. Ask your doctor to help you demonstrate that you meet the criteria for this benefit. Also, your home health benefit should not be ended or reduced unless your doctor has ordered it.

If the home health agency you approach denies you the benefit by telling you it will not be covered, you have the right to ask them to provide the service and submit the claim to Medicaid for payment. However, the agency might first request that you pay for the service or that you agree to pay for the service if the claim is denied.

The Medicaid home health service is a benefit that you are entitled to receive. However, getting this important benefit is often difficult and discouraging. If you have tried and have been denied, you may benefit from the assistance of an Elder Law attorney.

The information in this article was prepared as general and supplemental information and may not be applicable to the reader's particular legal needs or circumstances. It should not be relied upon as a substitute for legal or other professional services. For such services consult a competent professional advisor.

M. Robin Morris, R.N., L.L.C., Attorney At Law, 164 Waccamaw Medical Park Court, Conway, S.C. 29528; Tel. 843-347-7998. Member of National Academy of Elder Law Attorneys. ©1998