Medicare Home Health Care in New York: Who Qualifies, What It Costs, How to Find an Agency

Who qualifies for Medicare home health care

Medicare’s home health benefit is short-term, skilled, doctor-directed care at home. To use it, all of these must be true:

1. You are under the care of a doctor or allowed provider, such as a nurse practitioner, clinical nurse specialist or physician assistant, and the care follows a plan of care they set up and review regularly.
2. They certify that you need at least one skilled service: intermittent skilled nursing (other than only drawing blood), physical therapy, speech-language pathology, or continued occupational therapy.
3. They certify that you are homebound.
4. A doctor or allowed provider has seen you in person, within required timeframes, for the condition that is the reason for home care. A visit with your primary care doctor can count.
5. A Medicare-certified home health agency provides the care.

If you meet those conditions, the number of visits is not capped. What ends coverage is the need: when you no longer require skilled care, or are no longer homebound, the benefit stops.

What “homebound” means

People often assume homebound means bedbound. It does not. Medicare considers you homebound if leaving home is not recommended because of your condition, or if you have trouble leaving without help, and leaving takes a major effort. The help can be a cane, a walker or wheelchair, crutches, special transportation or another person.

You can still leave home for medical treatment, and for short, infrequent trips such as a haircut, a walk around the block, or a family event such as a funeral or graduation. Going to adult day care or religious services does not disqualify you.

For a New Yorker in a walk-up apartment, the stairs are often the whole case. Tell the doctor exactly what it takes to get down to the street and back, because the certification rests on that description.

What Medicare covers at home, and what it does not

“Intermittent” has a definition. Skilled nursing is intermittent if it is needed fewer than 7 days a week, or daily for less than 8 hours a day for up to 21 days, which Medicare may extend in exceptional circumstances. Combined nursing and aide care must stay under 8 hours a day and at or under 28 hours a week, or up to 35 hours in limited situations. Someone expected to need full-time skilled nursing for a long stretch usually does not qualify.

What it costs

Medicare pays a certified agency one payment for each 30-day period of care, and the agency agrees to accept the Medicare-approved amount. That is why a certified agency should not bill you for covered visits.

Before services start, the agency should explain, in writing and out loud, what Medicare will and will not pay for. If it plans to give you something Medicare probably will not cover, for instance because you are not homebound or need only personal care, it must give you an Advance Beneficiary Notice of Noncoverage (ABN) first. You can ask the agency to bill Medicare anyway so Medicare makes an official decision. That choice is Option 1 on the form, the only one that keeps your right to appeal. How the ABN works and how to appeal.

In a Medicare Advantage plan, the plan covers home health but may require you to use agencies it contracts with and may require approval first. Check the plan’s materials or call member services before choosing an agency.

Your situation and what to do

How to find a certified home health agency in New York

You have a say in which agency you use, and your doctor or hospital discharge planner should honor your choice, though availability and your insurance can narrow it.

When the agency says your care is ending

The agency should give you a written Notice of Medicare Non-Coverage at least 2 days before it ends your services. If you think it is too soon, follow the notice’s instructions to ask for a fast appeal. An independent reviewer, the Beneficiary and Family Centered Care Quality Improvement Organization for your state, looks at your records and talks to your doctor, and you should generally hear back no later than 3 days after the end date on the notice. 1-800-MEDICARE can give you that organization’s number.

If the reviewer agrees with you, Medicare keeps covering the care. If not, you pay for services after the date on the notice, and the agency must give you a cost estimate first. A separate notice, the Home Health Change of Care Notice, is required when an agency reduces or stops some services, for example because your doctor did not renew an order.

Where Medicare ends and Medicaid begins

This is the line that matters most for New York families. Medicare home health is skilled and temporary. Help with daily living over months, the aide who comes every morning, is a Medicaid benefit in New York, arranged through personal care, CDPAP or a Managed Long Term Care plan. People with both programs are dual eligible: Medicare pays first for skilled visits and Medicaid covers the long-term help.

For free, unbiased help with a Medicare home health question, call HIICAP, New York’s Medicare counseling program, at 1-800-701-0501, or the Medicare Rights Center at 800-333-4114.