Home Health Services Information Bulletin #10 - 6/7/01 Under the federal Medicaid/medical assistance statute, the three home and community-based services intended to avoid unnecessary institutionalization in nursing homes are: (1) Waiver services; (2) the Personal Care Option (discussed in Information Bulletin # 8, 4/11/01); and (3) Home Health Services. The present Information Bulletin discusses Medicaid's "Home Health Services" and how advocates can use Home Health Services to avoid institutionalization. Looking at the total long term care expenditures in fiscal year 2000, States spent only 3% for Home Health Services, as compared to 58% for nursing homes. That ratio must be significantly changed as we transition from Medicaid's institutional bias to one that focuses on community services.  I. GENERAL INFORMATION ABOUT HOME HEALTH SERVICES Home Health Services are MANDATORY and are an entitlement to persons who meet your State's nursing home level of care criteria.  To be entitled to Home Health Services, a person does NOT have to be in a nursing home NOR be discharged from a nursing home. Rather, a person need only be ELIGIBLE for nursing home care as your State defines the "level of care" (e.g., number of ADLs). States have incorrectly used Medicare's "skilled nursing" standard for Medicaid. States cannot limit Home Health Services to only persons who require skilled nursing or therapy services (as happens with Medicare). Make sure your State applies this correctly.  Currently, most States use SSI as the financial eligibility for Home Health benefits. Since eligibility for nursing homes can be as much as three times the SSI level, it is an unresolved legal question whether the financial eligibility for Home Health Services should not be the same as for nursing homes. Your State can require that the eligibility be the same. A person is eligible for Home Health Services whether or not the person is "homebound." Medicare's home health definition of "homebound" CANNOT be used for Medicaid's home health, even though many States still do.  Home Health Services MUST include nursing, medical supplies, home health aides, durable medical equipment and appliances that can be used in the home. States have the OPTION of providing PT, OT, speech and audiology services. Since people in nursing homes receive these services, you should advocate that your State provide them as part of Home Health Services.  Home Health Services cannot be limited to a State's "list" of services. A person has the right services not on the State's list, IF your doctor determines a Home Health Service is "medically necessary" and it's a part of the doctor's written plan of care. "Medical necessity" traditionally includes the treatment, prevention, palliative of a disease, illness or disability. For persons with disabilities, medical necessity should also include a service necessary for activities of daily living. The service must be consistent with good medical practice and provided for medical reasons and not primarily for convenience. There also must be a medical need to provide the service in the home. II. POSSIBILITIES FOR ADVOCACY USING THE HOME HEALTH SERVICES Persons should be able to receive home health services if, for example: a person needs assistance getting in and out of bed, going to an outpatient setting would be a medical hardship, extensive travel would be required to the outpatient setting, or person cannot perform heath care task without assistance. You can think of others. Home Health Services have been limited by States based on frequency of service and/or over how many days or weeks the service will be provided. This limit on Home Health Services probably is illegal. Remember, a Medicaid service must "be sufficient in amount, duration, and scope to reasonably achieve its purpose."  Keep in mind that for persons with disabilities, the objectives of Medical Assistance/Medicaid are "rehabilitation and other services to help .... attain or retain capability for independence and self care." Advocates must ensure that services are sufficient to meet these minimum needs of persons with disabilities. It is CRITICAL for us to challenge the limits States try to apply regarding number of hours per day, number of visits per month, and number of months of Home Health Services we receive. These restrictions may NOT be sufficient to reasonably achieve the objective of the federal law regarding "independence and self care. " Many Home Health Services are unnecessarily based on the "medical model". We must illustrate how money can be saved by making Home Health benefits less medicalized. The dollar limits of Home Health Services must be related to what the State would spend in the nursing home. Any amount less may force the person to become institutionalized. While the Home Health Services may seem "technical," advocates must understand how States can design and increase Home Health Services and keep people out of nursing homes. Where States develop a comprehensive (less medical) Home Health benefits, especially in combination with attendant services (e.g., via the Personal Care Option or Waivers), many persons will be able to receive services in their homes instead of institutions. The 2001 Disability Odyssey.  - Steve Gold