Your Medical Condition Does Not Have to Improve to Qualify for Medicare Coverage

An important federal case called Jimmo v. Sebelius, set new standards where Medicare beneficiaries who receive skilled nursing and/or skilled therapy can qualify for Medicare extended coverage for homecare services when:

  1. The person is either homebound or can go out, but the person needs the assistance of another or of a supportive device to travel outside the home.
  2. A physician orders and certifies that the skilled care is needed.
  3. A physician or other health care professional has a face-to-face meeting with the individual prior to certifying the individual’s need for home health care.
  4. A document about the face-to-face meeting, signed by a physician, is included in the home health care certification.
  5. The individual requires skilled nursing care on an occasional basis, or skilled physical therapy, speech-language pathology services or occupational therapy, only on a short term or occasional bases (to continue care once Medicare coverage has begun).
  6. The care is provided by Medicare-certified home health agency.
  7. If the above requirements are met, Medicare will also cover skilled care, as well as the necessary and reasonable in-home health aide services, social services, and some medical supplies.

Please note: Skilled care is not just physical therapy, it can be skilled nursing services such as wound care or testing. Occupational and speech therapy are also skilled services.

Remember: Medicare home health coverage is not just a short-term, critical care benefit. Under the Jimmo case, Medicare beneficiaries who qualify are eligible for home health coverage, when skilled care is reasonable and necessary, not only for rehabilitation, but also for maintenance and to prevent deterioration.

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