Medicare Coverage of Home Health Care
Benefit provides skilled nursing care, therapy and other aid to people who are largely or entirely confined to their homes
Services must be ordered by a doctor and provided by a Medicare certified home health care agency
Medicare can pay full cost of home health care for up to 60 days at a time. Period is renewable, if doctor recertifies at least once every 60 days that home health care services remain medically necessary
Qualifications
Part-time or “intermittent” skilled nursing care
- can be interpreted as “short-term”. Drawing blood is an exclusion
Skilled therapy:
- only physical therapy (PT) and speech therapy (ST) can be provided alone
- occupational therapy (OT) must be provided along with another skilled service but can stand alone once started with PT or RN opening case.
Need to meet all of following:
- Homebound – unable to leave home without considerable effort or without aid of another person or device such as wheelchair or walker or illness could get worse if you leave your home (note: this definition can vary with agency interpretation)
- Exceptions: medical treatment, religious services, licensed and accredited adult daycare services
- Must be certified by a doctor (or allowed practitioner including a nurse practitioner, clinical nurse specialist or physician assistant) as being in need of intermittent occupational therapy, physical therapy, skilled nursing care, and/or speech therapy
- Needs documented, face-to-face encounter with the doctor or allowed practitioner no more than 90 days before or 30 days after the start of home health care
- Plan of care needs to be established by the doctor or allowed practitioner and reviewed regularly. Plan should include what services are needed, how often, who will provide them, what supplies are required and what results the medical professional expects. The plan of care needs to be reviewed and recertified at least once every 60 days
- Medicare has approved the agency providing the care
Home health care benefits
Either element of original Medicare (Part A hospital insurance and/or Part B doctor visits and outpatient treatment) may cover home care. Services include:
- Skilled nursing care can include changing wound dressings, feeding through a tube, and injecting medicine, provided on a part-time or intermittent basis. Combined home nursing and personal care cannot exceed 8 hours/day or 28 hours/week except in limited circumstances. If full-time or long-term nursing care is needed, it will probably not qualify under Medicare.
- However, most if not all agencies will not be able to provide this amount of nursing care and will require a willing and teachable caregiver to assist with dressing changes, wound care, tube feeds, intravenous antibiotics with ongoing RN oversight
- Home health aides to assist with personal activities such as bathing, dressing, or toileting if needed due to illness or injury. Only covered by Medicare if also receiving skilled nursing or therapy
- Occupational, physical and speech therapy with professional therapists when the services are specific, safe and effective treatment for condition. Amount, frequency and time period of services need to be reasonable and need to be complex or only qualified therapists can do them safely and effectively
- To qualify:
- Condition must be expected to improve in a reasonable and generally predictable period of time or
- Need a skilled therapist to safely and effectively make a maintenance program for the condition
- No double dipping/ no OT alone
- Medical social services include counseling for emotional or social concerns related to illness or injury if receiving skilled care and help finding community resources
- Medical supplies such as catheters and wound dressings related to condition when home health care agency provides them. It can include durable medical equipment from the home health care agency, such as walkers or wheelchairs, but Medicare only covers at 80%.
- Home health care agencies will provide medical supplies related to wound care/ostomies, but most agencies will not provide DME supplies such as walkers or wheelchairs
- To qualify:
What's not covered by Medicare
- 24-hour care at home
- Custodial or personal care when it is only care needed
- Household services defined as cleaning, shopping, laundry when they are not related to care plan
- Meal delivery
Do I qualify for home health care?
- Am I homebound?
- If unable to leave the home without considerable effort or without the aid of another person or device such as a wheelchair or walker or leaving the home is not medically advised, such as needing to be on bedrest for wound care. Remember this definition can vary with agency interpretation
- Do I have a skilled care need?
- Nursing care – is it short-term? Do you have a trainable caregiver?
- Physical therapy, occupational therapy, speech therapy
- Cannot be getting same services in another setting while getting home health PT, OT, ST
What documentation is needed?
- Order/certification from medical professional
- Face to face encounter with medical professional no more than 90 days before or 30 days after start of home health care
- Plan of care needs to be established by the medical professional and reviewed regularly. Plan should include what services are needed, how often, who will provide them, what supplies are required and what results the medical professional expects
How do I find an agency?
- Medicare: Find Healthcare Providers: Compare Care Near You | Medicare
- Doctor’s office/resources (social worker/nurses)
- County/Public health dept
What if I only need custodial care or personal care?
- Explore community resources
- State Medicaid waiver programs
- Area agency on aging
- Independent living center
- Paying for In Home Care and In Home Nursing (aarp.org)
Definitions
Intermittent care – defined at skilled nursing care that’s needed fewer than 7 days a week, daily for less than 8 hours each day for up to 21 days. In some cases, Medicare may extend the 3-week limit if medical professional can predict when need for daily skilled nursing care will end. As noted previously, most agencies cannot staff this amount of care and have the goal of training a family member/caregiver
Custodial or personal care – bathing, dressing, using the bathroom
Catheter care and changing catheter – skill level varies by state. Check individual state board of nursing regulations or agency rules
Bowel program – skill level varies by state. Check individual state board of nursing regulations or agency rules
Home health aide - health care paraprofessionals and must meet state-set training requirements.
Advance Beneficiary Notice (ABN) is a waiver of liability and a notice a provider gives before a service is rendered based on Medicare coverage rules if the provider has reason to believe Medicare will not pay for the service. Only applicable with Original Medicare, not with Medicare Advantage Plans
Things to remember
If you have a Medicare Advantage (Part C) plan, home health care agency must be within their network
Some Medicare Advantage plans may offer additional services not traditionally covered by Medicare
*Above information adapted from AARP website Does Medicare Cover Home Care or Caregiving Costs? (aarp.org) and Medicare Home Health Services Coverage (medicare.gov)
Resources
This website provides information regarding long-term care, area agency on aging, Medicaid, creative ways to finance:
Authorship
- Resource Sheet on Medicare Coverage of Home Health Care was developed by Kathy Hulse, LCSW, CCM, Roxanne Wasmer, LCSW, CCM as well as the CRT subcommittee of the ASCIP Advocacy Committee.
Disclaimer
- This information is intended for rehabilitation professionals and may be shared with consumers with SCI/D. This resource sheet is not meant to replace the advice from a medical / rehabilitation professional. Medical / rehabilitation professionals are encouraged to discuss this material with consumers in the context of their overall medical rehabilitation care.
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