The Medicare health benefit is a crucial source of health care financing for Medicare beneficiaries struggling to live independently in the community. Unfortunately, although beneficiaries are theoretically entitled to substantial coverage for health care, Medicare patients throughout the United States have experienced drastic reductions in health coverage. When Medicare coverage is unfairly denied, beneficiaries may be unable to afford the health care they need. Unable to live safely in the community, they may be forced to enter a nursing home. Vigorous advocacy can protect these patients' rights to coverage and care. The availability of Medicare-covered health care was significantly impacted by the Balanced Budget Act of 1997 (BBA'97)1 which made significant changes in the Medicare reimbursement system for care providers. While the BBA did not change the Medicare coverage criteria, the new capitated payment structures and certain other adjustments reduced care to many beneficiaries, particularly those with chronic conditions. Most other aspects of the health benefit, including coverage criteria and covered services, were left largely unchanged. Changes introduced by the BBA'97 are summarized in a separate section of these materials. COVERAGE General Unlike most other services covered under Medicare, the health benefit is available under both Parts A and B. The substantive coverage criteria are identical. Pursuant to BBA'97, however, Part A coverage is sometimes limited to 100 visits and sometimes hinges on a prior hospital or skilled nursing facility stay. Medicare provides for coverage of health services under Part A and Part B when the services are medically reasonable and necessary,2 and when:3 * The individual is to his or her (or homebound); * The individual needs skilled nursing care on an intermittent basis, or physical or speech therapy or, in the case of an individual who has been furnished health services based on such a need, but no longer needs such nursing care or therapy, the individual continues to need occupational therapy; * A plan for furnishing the services has been established and is periodically reviewed by a physician; and * Such services are furnished while the individual is under the care of a physician. Home Health Services Described If the triggering conditions described above are satisfied, the beneficiary is entitled to Medicare coverage for health services. Home health services include: * Part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse; * Physical, occupational or speech therapy; * Medical social services under the direction of a physician; * Part-time or intermittent services of a health aide. . . .5 In practice, the requirements that a patient is to his or her (usually called the rule), and that he or she need intermittent skilled nursing care or physical or speech therapy, assume fundamental im- portance. Generally, if these two preconditions can be met, the beneficiary will be able to establish eligibility for health coverage. THE HOMEBOUND RULE (CONFINED TO HOME) The requirement that a patient be homebound is described in detail in the Medicare statute as follows: . . . an individual shall be considered to be confined to his home if the individual has a condition, due to an illness or injury, that restricts the ability of the individual to leave his or her except with the assistance of another individual or the aid of a supportive device (such as crutches, a cane, a wheelchair, or a walker), or if the individual has a condition such that leaving his or her is contraindicated. While an individual does not have to be bedridden to be considered confined to the condition of the individual should be such that there exists a normal inability to leave home, that leaving requires a considerable and taxing effort by the individual, and that absences of the individual from are infrequent or of relatively short duration, or are attributable to the need to receive medical treatment. …