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Elder Law & Special Needs Planning

3 Things You Need to Know About Medicare and In-Home Care

February 6, 2020

While it has benefited millions of people, using Medicare can be overwhelming. For many, it may even be difficult to figure out if you qualify for Medicare in-home care and know what is and isn’t covered. 

Common questions about Medicare and In-Home care include: 

  • Does Medicare cover in-home care?
  • Does Medicare pay for long-term care?
  • What are the medicare long-term care benefits?
  • What are the myths around Medicare and long-term care?

In this article, we will answer some of your questions regarding Medicare and in-home care and show you three must know things about the program. 

How to Qualify For Medicare In-Home Care

First, let’s identify the ways that you or your loved one can qualify:

  • Unable to leave home without assistance (be homebound)
  • Requires skilled nursing care regularly, or skilled physical therapy, pathology services, speech-language, or occupational therapy 
  • Under care of a physician who must order the care, sign and certify a “Plan of Care”
  • Attended a face-to-face meeting with a physician prior to certifying the need for home care
  • Documented evidence of your face-to-face meeting with the physician that they have signed and dated
3 Things You Need to Know About Medicare and In-Home Care

If the requirements are met, Medicare will cover all the necessary home health aides, medical social services and some of the supplies needed. 

Any patient who meets the Medicare criteria will be able to apply and qualify for coverage.

What’s Covered Under Medicare

With Medicare you can have the following items covered:

  • Intermittent skilled nursing 
  • Physical therapy 
  • Speech-language therapy
  • Up to 35 hours of home health aide a week that can be used to provide personal care like bathing, grooming, feeding and dressing 
  • Occupational therapy
  • Medical social services
  • Medical supplies

Medicare home health coverage is not just for short-term conditions. Under the law, those who meet the requirements for Medicare and are eligible for the home health coverage are covered as long as skilled care is necessary and reasonable. 

Medicare coverage must be available for:

  • Any care used to improve, maintain or slow the health decline of a patient 
  • Any care used for any long-term or chronic conditions as well as any short-term conditions a patient may have 
  • Care that doesn’t have a cap on how long the services can continue on for 
  • The care that starts from the patient's home or after they were an inpatient 

If a home health agency tells you that Medicare doesn’t cover the necessary care you need, the three things listed below might help you to push back and receive the help you’re entitled to. 

1. Care Providers Do Not Have the Authority to Certify Whether You Need Care Or Not

A home health agency or a care provider does not have any authority to determine whether or not you are certified for care. Only your physician or doctor can certify you for care and discharge you from care. 

3 Things You Need to Know About Medicare and In-Home Care

In a recent case study by the Center for Medicare Advocacy (, Mrs. Green (who has advanced multiple sclerosis) was told by the agency who supplies her care that Medicare was closing a ‘loophole’ and she would be discharged from their care.

Mrs. Green spends her time bed bound or in her wheelchair and had already been receiving very little care, far less than what is authorized by law. A home nurse would come to her home twice a week to check on her and change her suprapubic catheter as well as help her bathe twice a week. 

The agency told them the care would end because;

“(1) Her condition was “stable”, (2) The agency had adopted a policy not to provide long-term care, and (3) Medicare was changing its payment system on January 1, 2020.” (Home Health Practice Guide).

The Greens decided to contact the Center for Medicare Advocacy for help as they were devastated by the potential loss of their home health care. 

After the Greens got in contact with the center, they were told that “Medicare coverage law has not changed” and they were still entitled to their home health care. After getting in contact with Mrs. Green’s doctor, who had not discharged her, the agency agreed to continue the home care for Mrs. Green. She wasn’t discharged and her care remained as it was before.

Here’s what you should do if you find yourself in a situation where you have Medicare coverage and have problems accessing home health care.

Talk to the Doctor Who Certified You for Home Health Care 

If you’re having a problem with your Medicare coverage and home health access, one of the first things you should do is contact the doctor who ordered and certified your home health care. 

You should then urge them to communicate with the home health agency about whether or not the doctor:

  • Was consulted about the treatment
  • Agreed to discharge you
  • Is prepared to recertify you
  • Agreed to the discharge from Medicare home health care
  • Understands that your medical needs are listed as a Medicare-covered skilled nursing service
  • Knows that you meet the criteria for home health care

It is true that the payment system for Medicare changed as of January 1, 2020, but the Medicare coverage criteria remained the same as it always was. 

The new Medicare payment model does not mean that patients will no longer qualify for the covered care they need - as it is authorized under the law. 

2. Medicare Can Pay for Long-Term Care in Certain Situations

Many people ask if Medicare covers long-term care and in some cases, it can.

The coverage laws for Medicare haven't changed, which means that your home health care doesn’t have a definite ending. As long as you continue to meet the coverage criteria for Medicare, you’ll be covered. 

Home health agencies cannot decide on their own to stop providing you with a long-term home care program. It’s the law.

3. The Improvement Standard is a Myth

The “Improvement Standard” is the idea that Medicare coverage can only be extended if the care that is being provided was improving the patient's condition. This is false as Medicare will continue to give care as long as you are within the criteria for coverage. The coverage criteria does not include improvement.

Because of the mythical “Improvement Standard,” those who have long-term conditions and those who are in need of rehabilitation services are often denied the care they need. This illegal practice has resulted in vital care being denied to thousands of individuals on the terms that their condition was stable, chronic or not improving and that the necessary treatments or care were for patients who were improving.

To avoid situations like Mrs. Green’s, it’s important to have a long-term care plan in place and to be educated on your rights to care covered by Medicare. Call The Chubb Law Firm today at (916) 241-9661 to schedule a consultation to review your needs and discuss your options for long-term care planning.

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Heather was wonderful. She explained, in understandable terms, why it is important to establish an estate plan. I never realized what would happen, without a plan in place, and we could not bear the thought of our child in arms of absolute strangers while the court system sorted out his future.

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