Medicare Home Health Benefit
Reduction Appeals

 

If you qualify, Medicare will cover your home health benefits entirely, and while under the law there's no limit on the length of time you will be covered, in practice coverage is limited. This is unfortunate as Medicare home health benefits can mean the difference between staying at home or requiring hospital care or nursing home placement. While the government insists that it has not changed the criteria for who is eligible for home care services, home health agencies have cut back on services they provide in order to make their own budgets balance.

This means that Medicare recipients must advocate for the services they need. If you have to appeal a termination of service, the good news is that most people who appeal Medicare home health benefits win their cases. At the first level of review, 39 percent are successful, and on appeal to an administrative law judge, 81 percent are successful. The bad news is that you have to pay privately for the care in order to have an appealable issue. This is because the issue on appeal is not the termination of a service, but the denial of Medicare payment for the service. As a result, many beneficiaries simply try to make do without the care or hire help on their own without the training and supervision provided by home health agencies.

Most Medicare beneficiaries are not informed of their appeal rights when given notice that their home health care benefits will be terminated. Attorneys have filed a nationwide class action suit on behalf of homebound seniors seeking advance notice of any termination of benefits for Medicare home health coverage, as well as notice of the ability to appeal such a denial before the termination occurs. If your benefits or those of a family member are reduced or terminated, you should take the following steps:

1. Ask your home health agency to explain the cutback and write down its answer. Ask the agency to give you written notice of the cutback or termination of service.

2. Ask your physician to call the agency to urge it not to cut back the services and to provide a letter verifying the level of care you need. This can be essential to whether you ultimately receive the benefits you deserve.

3. Consult your attorney or a Medicare assistance agency in your state to determine whether you likely would be successful on appeal.

4. If you decide to appeal, do so immediately, and arrange with the home health agency to pay privately for the services pending the result of the appeal.

-Linked from: ElderLaw News from ElderLawAnswers, June 09, http://www.elderlawanswers.com/elder_info/elder_article.asp?id=2783#7, retrieved 6/9/10.

 

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