If you’re looking for an answer to the question, “what does Medicare cover for home health care in America?”, you’ve probably typed it into google and immediately closed the tab. The volume of information and the level of detail can quickly become confusing and overwhelming (and there’s a good chance you’ll end up with more questions than when you started).
We’ve broken this important query down into a series of frequently asked questions, looking at what home health services can be offered by a home health agency, what services aren’t covered, and who is eligible.
If you’re a health professional exploring the idea of establishing a home health agency or are trying to determine which services you can and can’t offer, this article will help.
What is Home Health Care?
Home health care covers a wide range of health services administered in a client’s home following an injury or illness. For many, it’s an ideal solution as it’s cost-effective, convenient, and just as effective as the care that clients would receive in a hospital or clinic.
Sometimes called home-care, supportive care, or in-home care, home health care is provided by a qualified professional in a client’s own home, rather than in a clinic or other group accommodation.
What Home Health Services Are Available?
Under Medicare Part A (which covers hospital insurance), along with Medicare Part B (medical insurance), there are a number of home health services available, including:
- Physical therapy;
- Occupational therapy;
- Speech-language pathology services;
- Intermittent (part-time) skilled nursing care;
- Medical social services;
- Intermittent (part-time) home health aide services for personal hands-on care;
- Osteoporosis drugs (injectables for women).
The services will usually be coordinated by a home health care agency based on what your doctor has ordered for you.
What Isn’t Covered?
While Medicare covers home health care, it won’t cover around-the-clock care (24 hours a day) or meal deliveries. In addition, if it’s the only care that the client requires, homemaker services (including cleaning and laundry) and personal care (such as bathing and dressing) aren’t covered.
How Do You Become Certified as a Home Health Provider?
A Home Health Agency (HHA) follows policies set by a group of medical professionals (including one or more physicians and registered professional nurses to provide skilled nursing and therapeutic services). As a home health agency, you’ll also need to maintain clinical records, be licensed and meet federal health and safety requirements.
Who Is Eligible for In-home Care?
In order to access the available home health care services, your client will need to have Medicare Part A and/or Part B. In addition, they need to meet the following conditions:
- They must be under the care of a registered doctor, and their case must be reviewed regularly by their doctor.
- Their doctor must certify that they need skilled nursing care or therapy.
- They must require physical, occupational, or speech therapy for a limited period of time.
- They must be housebound, meaning that they are unable to leave home without considerable effort or support.
- They must have certification from a doctor that they’re housebound following a documented encounter with their doctor no more than 90 days before or 30 days after their home health care starts.
- They are under an established plan of care from their doctor that is reviewed regularly and includes what services are needed, how often they are needed, who will provide them, what supplies are required, and what results are expected.
- They must only require part-time skilled nursing (excluding drawing blood).
- You, as the home health agency providing care, must be Medicare certified.
A client will not be eligible for home health benefits if they require more than intermittent skilled nursing care. However, they may leave their home for medical treatment for short outings such as religious services. Your client will still be eligible if they attend adult daycare.
For more on who qualifies for services, have a look at Medicare’s website.
How Much does Medicare Cover for Home Health Care?
If your client has original Medicare, they don’t pay anything for home health services although they will be liable for a co-pay of 20% of the Medicare-approved amount for durable medical equipment (such as wheelchairs, hospital beds, crutches, walkers, kidney machines, ventilators, oxygen, monitors, and pressure mattresses).
Before starting with home health care, you, as the agency, will need to advise your client what costs will be incurred and which are covered by Medicare. You’ll also need to inform them of any services that aren’t covered by Medicare. This should be communicated in-person and in writing and you’ll also need to provide them with an “Advance Beneficiary Notice” before any non-Medicare services are provided.
In some states (including Florida, Michigan, Illinois, Massachusetts, and Texas) you may submit a pre-claim review request to Medicare. This helps you and the client determine whether Medicare is likely to cover the services.
The specific amount a client will owe for non-Medicare covered services will depend on:
- Any other medical insurance they have;
- Their doctor’s rates;
- If their doctor accepts assignment;
- The type of treatment facility;
- Where they get their tests or services.
In some cases, your client’s doctor may recommend a treatment plan that requires more regular treatments than are covered by Medicare, or they may recommend services that aren’t covered. If this happens, the client will be liable for the costs.
Is Skilled Nursing Care Covered?
Medicare covers intermittent (or part-time) nursing services. This means that nursing care is provided fewer than seven days a week, or for less than eight hours a day, up to a limit of 21 days. In some cases, Medicare will extend the window if a doctor can provide an accurate assessment of when the care will end.
Skilled nursing services are usually employed to help treat an illness or assist the patient with recovering from an injury. The nurse needs to be licensed to administer the medical treatment they need (such as wound dressing, injections, and catheter changes).
What Home Health Services Are Provided by Aides?
Home health aides assist with personal activities which include dressing, bathing, and going to the bathroom if clients need these services following an injury or illness. They will only be covered by Medicare if the client also receives skilled nursing or therapy.
When is Physical, Occupational, or Speech Therapy Covered by Medicare?
Physical therapy will be covered by Medicare when it will help the client regain strength or movement after an illness or injury. The same holds true for occupational therapy where the goal is to restore functionality, and for speech therapy to help patients relearn how to communicate.
The services will only be covered if they are expected to result in an improvement within a predictable period of time. Additionally, the frequency, duration, and number of services must be reasonable and provided by a qualified therapist. To be eligible for the services your condition must either:
- Be expected to improve,
- Require a maintenance program from a skilled therapist, or
- Require a skilled therapist for maintenance.
Professional therapists will restore or improve the client’s ability to perform routine everyday tasks, speak or even walk following an illness or injury. They may also help prevent a condition from worsening and will only be covered if the services specifically, safely and effectively treat the client’s condition.
What Durable Medical Equipment is Covered by Medicare?
The cost of durable medical equipment is covered by Medicare if it is deemed medically necessary, and has been prescribed by a doctor for use at home. The list of covered durable medical equipment includes:
- Wheelchairs (electric or manual);
- Canes or walkers;
- Hospital beds;
- Blood sugar monitors.
Your client will pay 20% of the Medicare-approved amount for the equipment, and they will be liable for any remaining deductible under Medicare Part B.
What are Medical Social Services?
These are medically prescribed services to help the patient cope emotionally in the aftermath of an illness or disease. Examples of medical social services that Medicare covers include in-home counseling by a licensed therapist or social worker. Keep in mind that these services are only covered by Medicare if the client is receiving skilled nursing care at home.
How has COVID-19 Affected Home Health Services?
During the COVID-19 pandemic, Medicare has authorized nurse practitioners, clinical nurse specialists, and physician assistants to provide home health services without requiring certification from a physician.
If you have clients with Medicare insurance that require home health care, there is a range of services that you may be able to offer in order to help with an injury or illness. Where possible, it is ideal to get a pre-claim review request for a full breakdown of what you can expect Medicare to cover for your client.
This article was originally published in 2020 and has been updated for comprehensiveness and accuracy.