How Medicare Covers Home Health Services
By Greg Dill
A couple of years ago, my father, well into his 70s, finally bought himself a high-performance automobile.
The kids and grandkids had all grown up, so there was no need for a larger car. And heck, he had waited a long time to drive something fun.
All was fine with the new car until my mother broke her hip, had surgery, and needed extensive outpatient physical and occupational therapy.
Getting into and out of a sporty car isn’t easy for someone using a walker and cane. So I got a phone call asking what could be done. (Actually, I think he was angling for my new minivan, whose video screens would give him something to do during mom’s therapy sessions.)
But I told him he didn’t need to take mom to a clinic or hospital. As a Medicare beneficiary, she could receive most of the therapy in her own home.
Medicare covers a variety of heath care services that you can get in the comfort and privacy of your home. These include intermittent skilled nursing care, physical therapy, speech-language pathology services, and occupational therapy.
Such services used to be available only at a hospital or doctor’s office. But they’re just as effective, more convenient, and usually less expensive when you get them in your home.
To be eligible for home health services, you must be under a doctor’s care and receive services under a plan of care established and reviewed regularly by a physician. He or she also needs to certify that you need one or more home health services.
In addition, you must be homebound and have a doctor’s certification to that effect. Being homebound means leaving your home isn’t recommended because of your condition, or your condition keeps you from leaving without using a cane, wheelchair or walker; special transportation; or getting help from another person.
Also, you must get your services from a Medicare-approved home health agency.
If you meet these criteria, Medicare pays for covered home health services for as long as you’re eligible and your doctor certifies that you need them.
For durable medical equipment (like a walker or wheelchair), you pay 20 percent of the Medicare-approved amount.
Skilled nursing services are covered when they’re given on a part-time or intermittent basis. In order for Medicare to cover such care, it must be necessary and ordered by your doctor for your specific condition. Medicare does not cover full-time nursing care.
Skilled nursing services are given by either a registered nurse or a licensed practical nurse under an RN’s supervision. Nurses provide direct care and teach you and your caregivers about your care. Examples of skilled nursing care include: giving IV drugs, shots, or tube feedings; changing dressings; and teaching about prescription drugs or diabetes care.
Before your home health care begins, the home health agency should tell you how much of your bill Medicare will pay. The agency should also tell you if any items or services they give you aren’t covered by Medicare, and how much you’ll have to pay for them.
This should be explained by both talking with you and in writing. The agency should give you a notice called the Home Health Advance Beneficiary Notice before giving you services and supplies that Medicare doesn’t cover.
What isn’t covered? Some examples:
- 24-hour-a-day care at home;
- Meals delivered to your home;
- Homemaker services like shopping, cleaning, and laundry (when this is the only care you need, and when these services aren’t related to your plan of care);
- Personal care given by home health aides like bathing, dressing, and using the bathroom (when this is the only care you need).
If you get your Medicare benefits through a Medicare Advantage or other Medicare health plan (not Original Medicare), check your plan’s membership materials. Contact the plan for details about how the plan provides your Medicare-covered home health benefits.
If your doctor decides you need home health care, you can choose from among the Medicare-certified agencies in your area. (However, Medicare Advantage or other Medicare plans may require that you get services only from agencies they contract with.)
One good way to look for a home health agency is by using Medicare’s “Home Health Compare” web tool, atwww.medicare.gov/HHCompare. It lets you compare agencies by the types of services they offer and the quality of care they provide.
For more details on Medicare’s home health benefit, please read our booklet, “Medicare and Home Health Care.” It’s online at https://www.medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf.
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