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 are available, what services aren’t covered, who is eligible, and what costs you can expect to incur.
What is home health care?
Home health care covers a wide range of health services administered in your home following an injury or illness. For many, it is an ideal solution as it is cost-effective, convenient, and just as effective as the care that you 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 your 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 is the only care you need, homemaker services (including cleaning and laundry) and personal care (such as bathing and dressing) are not covered.
Who is eligible for in-home care?
In order to access the available home health care services, you will need to have Medicare Part A and/or Part B. In addition, you need to meet the following conditions:
- You must be under the care of a registered doctor, and your case must be reviewed regularly by your doctor.
- Your doctor must certify that you need skilled nursing care or therapy.
- You must require physical, occupational, or speech therapy for a limited period of time.
- You must be housebound, meaning that you are unable to leave home without considerable effort or support.
- You must have certification from a doctor that you are housebound following a documented encounter with your doctor no more than 90 days before or 30 days after your home health care starts.
- You are under an established plan of care from your 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.
- You must only require part-time skilled nursing (excluding drawing blood).
- The home health agency providing care must be Medicare certified.
You will not be eligible for home health benefits if you require more than intermittent skilled nursing care. However, you may leave your home for medical treatment for short outings such as religious services. You will still be eligible if you 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 you have original Medicare, you don’t pay anything for home health services. There is 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 should be advised by your agency on what costs will be incurred and which are covered by Medicare. They will also inform you of any services that aren’t covered by Medicare. This should be communicated in-person and in writing and you will also be provided with an “Advance Beneficiary Notice” before any non-Medicare services are provided.
In some states (including Florida, Michigan, Illinois, Massachusetts, and Texas) your home health agency may submit a pre-claim review request to Medicare. This helps you and the agency as you know whether Medicare is likely to cover the services.
The specific amount you owe for non-Medicare covered services will depend on:
- Any other medical insurance you have;
- Your doctor’s rates;
- If your doctor accepts assignment;
- The type of treatment facility;
- Where you get your tests or services.
In some cases, your doctor may recommend a treatment plan that requires more regular treatments than are covered by Medicare, or they may recommend services that are not covered. If this happens, you will be liable for the costs, so it is important to ask questions so that you know why they are being recommended, and what costs you will need to pay out-of-pocket.
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 your 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 you 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 you need these services following an injury or illness. They will only be covered by Medicare if you also receive 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 patient 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 your 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 your 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.
You will pay 20% of the Medicare-approved amount for the equipment, and you 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 includes in-home counseling by a licensed therapist or social worker. Keep in mind that these services are only covered by Medicare if you are receiving skilled nursing care at home. They can also help you find community resources if you need them.
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.
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If you have Medicare insurance and require home health care, there is a range of services that can help you as you recover from an injury or illness. To ascertain whether you are eligible and what does medicare cover for home health care, you can either call Medicare and ask them to refer you to a registered doctor in your area, or you can make an appointment with your physician to explore the available options.