Q. What services qualify for Medicare home health coverage?
Your doctor must determine that you are homebound and need medical care in your home, and a plan must be prepared for your care at home. This means it is a taxing effort for you to leave your home. You can still be considered homebound if you occasionally go to the barber or beauty shop or for a walk around the block or a short drive or even to routine medical appointments.
The care you need must include intermittent (not full time) skilled nursing care, or physical therapy or speech language services.
The home health agency serving you must be approved by the Medicare program.
Q. What’s Covered?
If you meet the conditions to qualify for home health care, Medicare will pay for:
Skilled nursing care either on an intermittent or part-time basis. Skilled nursing includes services and care that can only be performed safely and effectively by a licensed nurse.
Home health aide services either on an intermittent or part-time basis. Home health aide services include assistance with personal care such as bathing, using the toilet, or dressing. These types of services do not require the skills of a licensed nurse.
Physical therapy as often and for as long as it is medically necessary and reasonable. Physical therapy includes exercise to restore movement and strength to an injured arm or leg, and training in getting into and out of a wheelchair or bathtub.
Speech language pathology as often and for as long as it is medically necessary and reasonable. This type of therapy includes exercises to restore speech and swallowing.
Occupational therapy as often and for as long as it is medically necessary and reasonable. Occupational therapy helps you to achieve independence in daily living by learning new techniques for eating, dressing and performing other routine tasks.
Medical social services to assess the social and emotional factors related to your illness, counseling based on this assessment, and searches for available community resources.
Medical supplies such as wound dressings.
Q. What’s Not Covered?
Medicare does not cover the following:
– 24-hour care at home.
– Self-administered prescription drugs.
– Meals delivered to the home.
– Homemaker services such as shopping, cleaning and laundry.
– Personal care provided by home health aides, such as bathing, toileting, or providing help in getting dressed when this is the only care you need. Medicare classifies this as “custodial care” because it could be provided safely and reasonably by people without professional skills and training. Medicare does not pay for “custodial care” unless you are also getting skilled care such as nursing or therapy and the custodial care is related to the treatment of your illness or injury.
Q. What is a Plan of Care?
A plan of care directs the type of services and treatment you receive. Your doctor will work with a home health nurse and then decide:
-what kind of services you need
-what type of health care professional should provide your services
-how often you will need the services
-the kind of home medical equipment you will need
-the kind of food you may need and
-the outcome your doctor expects from the services you receive.
The home health agency staff provides care according to your approved plan of care. Your doctor and home health agency personnel review your plan of care at least every 60 days or as often as needed. Home health professional staff must notify your physician promptly of any changes which require a change in your plan of care.
Q. How Long Will Services Continue?
Medicare pays for covered home health services for as long as they are considered medically reasonable and necessary. However, skilled nursing care and home health aide services are covered on a part time or intermittent basis. There are limits on the number of hours and days of care you can receive in any given week for certain types of services.
For purposes of qualifying for home health benefits, Medicare defines “intermittent” as skilled nursing care that is needed or provided on fewer than seven days each week or less than eight hours each day over a period of 21days (or less).
Extensions can be made in exceptional circumstances when the need for additional care is finite and predictable.
For purposes of coverage, Medicare defines part-time/intermittent care as skilled nursing or home health aides services that are provided (combined) for any number of days per week so long as they are furnished less than 8 hours per day and 28 or fewer hours each week. The weekly maximum number of hours of care can be increased from 28 to 35 if Medicare determines that your condition requires additional care.
Q. What Can You Be Billed For?
The home health agency submits claims to Medicare for payment. Medicare pays the approved cost of all covered home health visits. You may be charged for medical services and supplies that Medicare does not cover.
Before your care begins, the home health agency must tell you how much of your bill Medicare or other Federal programs should pay. The agency must also tell you if any items or services they provide are not covered by Medicare and how much you will have to pay for them. This must be explained orally and in writing.
If you are eligible for Medicaid it might be possible to get services in addition to those covered by Medicare. Medicaid coverage differs from State to State, but in all States it covers basic home health care and medical equipment. In addition, Medicaid programs everywhere cover homemaker, personal care, and other services that are not covered by Medicare.
To be eligible for Medicaid, you must have very low income and few savings or other assets. For more information about whether you might be eligible and about what Medicaid covers in your State, contact your State Medicaid Agency.