A Medicare patient is entitled to have payment made for home health services provided in his or her residence. A patient's residence is wherever he or she makes his or her home. This may be his or her own dwelling, an apartment, a relative's home, a home for the aged or some other type of institution. However, an institution may not be considered a patient's home if the institution is a hospital or skilled nursing facility.
The Medicare rules do not prohibit a patient from having one or more places of residence. (A patient under a Medicare home health plan of care who resides in more than one place of residence during an episode of Medicare-covered home health services will not be disqualified for purposes of eligibility.) For example, a person may reside in a principal home and also a second vacation home, mobile home or the home of a caretaker relative. That the patient resides in more than one home and, as a result, must travel from one to the other, is not an indication that the patient should not be considered homebound. The requirements of homebound must be met at each location, e.g., considerable taxing effort.
Assisted Living Facilities, Group Homes and Personal Care Homes
An individual may be “confined to the home” for purposes of Medicare coverage of home health services if he or she resides in an institution that is not primarily engaged in providing the following services:
- Inpatient diagnostic and therapeutic services for medical diagnosis and treatment
- Care of disabled or sick people
- Rehabilitation services for injured, disabled or sick people
- Skilled nursing care or related services for patients who require medical or nursing care
If it has been determined the assisted living facility (also called personal care home or group home) in which the individual resides is not primarily engaged in providing the above-listed services, then Medicare will cover reasonable and necessary home health care furnished to the individual. Services to individuals who already have access to appropriate care from a willing caregiver are not considered reasonable and necessary to the treatment of the individual's illness or injury.
Individuals who reside in assisted living facilities may be eligible for coverage of Medicare home health services. A major consideration is the location of the individual within the assisted living facility in terms of the level and type of care provided by the facility. Medicare home health coverage is not a substitute for the required services by a facility. An individual's choice to reside in such a facility is a choice to accept the services the facility is offering to its patients.