Arthritis Today

Medicare Expands Access to Home Care

Qualifications for home-based PT and OT now include ‘maintenance care.’


It's a common-enough scenario: After joint surgery, 72-year old Mrs. Doe receives nursing and therapy services at home, paid for by Medicare. Nurses care for a surgical wound; therapists evaluate and adjust the exercises she does to restore some mobility and strength.

But after a few weeks of skilled nursing and therapy services, the home health agency through which she gets her home care decides to discontinue the therapist’s services. Why? Because while they help maintain her joint function, they are not likely to improve her condition: severe, debilitating arthritis that has left her largely homebound.

Until late last year, “improvement” was one of the criteria for continued Medicare payment of home care services. The so-called improvement standard was never officially part of Medicare home-care regulations; it was gradually adopted over time by providers and intermediaries (the organizations that pay the bills on behalf of Medicare).

In short: no improvement, no payment.

But patients and their advocates argued in court for almost two years that skilled maintenance care (to prevent a decline in function due to an illness) is crucial and that Medicare had an obligation to pay for it. In late 2012, the federal government agreed.

In November 2012, a federal judge gave initial approval to an agreement that strikes from policy manuals language about the improvement standard. And in January of 2013, the agreement became final.

Education Efforts

In addition, federal administrators will embark on a yearlong education campaign so that Medicare beneficiaries, their families, and health care providers understand the agreement and its impact.

“It is a big deal,” says Diane Omdahl, a registered nurse who recently launched 65 Incorporated, a service to help those on Medicare understand their benefits. “Agencies were denied reimbursement for care if patients didn’t show improvement. Consequently, the home health agency would become “gun shy” about accepting a client.

It’s not possible to estimate how many people with arthritis may have been denied – or simply not offered – home care because improvement was unlikely. But the federal government does keep track of home health diagnoses: In 2007, about 10 percent of all home health patients were diagnosed with arthritis (not including arthritis of the spine), and a typical patient was diagnosed with 4.2 medical conditions.

The Center for Medicare Advocacy (CMA), a national nonprofit based in Connecticut, is one of the parties that challenged in court the use of the improvement standard. CMA executive director Judith Stern estimates that because the suit was filed in January 2011, “tens of thousands” might have had care denied – and are therefore good candidates for an appeal.

She says her estimate doesn’t take into account the number of people who simply weren’t offered potentially helpful home care because agencies were worried that the improvement standard would make it difficult to get paid.

“What we’re seeing here is the tip of the iceberg,” Stern says.

Even though the improvement standard was overturned, patients should not assume all Medicare providers are up-to-date on the agreement. CMA has a free online information packet designed to help patients and caregivers understand their rights and how to deal with payors and health care providers.  

There’s a good reason health care professionals may not know about or understand the new guidelines under the agreement, says Omdahl of 65 Incorporated. Home care providers have spent decades relying on the improvement standard – and changing that “will involve turning the battleship around,” she says.

It’s important to remember that Medicare has several other requirements for payment and those are unchanged by the ruling Omdahl points out. For example:

  • A physician must prescribe home care.
  • A patient must be homebound. Brief, intermittent trips outside the house are OK, but Medicare regulations don’t clearly define “homebound,” she says.
  • The care must be skilled. Medicare will pay for a nurse or therapist, but not for the kind of general care provided by a home health aide, she notes.
  • The care must be necessary and reasonable.

But Omdahl warns, now that the improvement standard is gone, regulators might be even stricter as they evaluate claims against the criteria that remain.

Know Your Options

Patients who were denied Medicare home health benefits under the improvement standard after the lawsuit was first filed in January 2011, have several options, says Letha McDowell, an elder care attorney who practices in Virginia and North Carolina with the firm of Oast & Taylor. Her suggestions range from simple to more involved:

  • Contact the prescribing physician. At the very least, the physician’s order will help establish the need for home care.
  • Contact the home health agency. The agency may refile a denied claim. “If they’re going to get reimbursed, it’s advantageous for them to provide the care,” says McDowell.
  • Contact a third-party for help. Help might come from an elder care law firm, an advocacy organization, or patient care organizations.

If a physician prescribes skilled home care now, patients and their caregivers should ask the physician to tell them specifically what skilled service is needed, recommends Bill Dombi, vice president for law at the National Association for Home Care and Hospice in Washington, D.C. He notes, for example, that teaching a patient exercises to avoid contractures of the hand may require skilled therapy services. By comparison, a patient may not need skilled care to learn and carry out simple exercises that promote mobility and general good health.

If a payor were to raise a question about the need for skilled home care, it would be very helpful to have the physician’s assessment handy up front, Dombi says.

It’s likely that patients with chronic conditions such as arthritis will need skilled home care only intermittently, says Omdahl. After home care is prescribed, one of the first things a nurse or physical therapist will do is conduct a detailed assessment of a patient’s health and describe a personalized plan of care, she explains.

Depending on the individual patient’s situation, that plan of care might call for skilled care. For example, a registered nurse to teach a patient how to administer pain medication, or a physical therapist to help a patient with an assistive device such as a cane or fit the patient with a brace.

Skilled nursing can even include non-pharmacological approaches to pain medication, says Karen Carnes, a registered nurse for Interim HealthCare, a home care group based in Sunrise, Fla. A nurse might instruct a patient on how to use music or guided imagery, for example, to cope with an acute episode of pain.

Almost 1.5 million Americans receive some form of home care every day, and Medicare is the primary payor for about 57 percent of their home health visits, according to a report from the National Center for Health Statistics. Private insurers are not required to adopt Medicare’s guidelines, but in practice they often do, notes Carnes, who in her role as Interim’s chief clinical officer oversees both private and Medicare- and Medicaid-certified agencies. Still, private insurers, the primary source of payment for about 14 percent of visits, never had an improvement standard either officially or in practice, she says.

Patients, health care providers and payors have been embracing the new agreement since the preliminary November 2012 decision. “People are not being cut off as quickly,” says Oast & Taylor’s McDowell.