Many medical treatments have advanced to the point where they can be administered right in a patient’s own home rather than requiring a hospital or doctor’s office. This has made healthcare more convenient for patients, especially the elderly, who often find it safer, easier, and less expensive to have a home health care provider administer treatment for an illness or injury right in their own home. However, the question does Medicare pay for home health care often arises.
Does Medicare Pay for Home Health Care?
Medicare does pay for home health care in certain specific instances, for which a patient must qualify before getting treatment at home. Traditional Medicare, which is administered through the government, covers aspects of home care under Part A (hospital coverage) and Part B (doctor and outpatient coverage), but all home health care services must be ordered by a physician and provided by one of the 11,000 home health agencies that have been certified by Medicare.
To qualify for home health care services under Medicare, you must be considered homebound. This means that you are unable to leave your house due to illness or injury without the help of crutches, a wheelchair, special transportation, etc., or leaving your house is not suggested due to your physical condition. You may be able to leave your house for short periods for adult day care, doctor’s appointments, and religious services, among other outings, but doing so requires great effort.
You must be under the care of a physician and getting your situation reviewed regularly by a physician. Additionally, your doctor must certify that you need one or more of the following services:
- Intermittent skilled nursing services (not just for drawing blood)
- Physical therapy
- Speech-language pathology services
- Occupational therapy
Intermittent skilled nursing services are defined as requiring care for fewer than seven days per week and for less than eight hours per day. There is a 21-day limit on intermittent skilled nursing, but it can be recertified by your physician if they are able to determine when your need for skilled nursing services will cease. If you need skilled nursing on a full-time basis, you won’t qualify for home health care but will require a skilled nursing facility instead.
If you qualify for home health care coverage, you can receive benefits for the following services as long as they are deemed medically necessary for the treatment of your injury or illness.
Skilled Nursing Care
You can get skilled nursing care from a registered nurse (RN) or a licensed practical nurse (LPN); however, if you get your care from an LPN, it will be supervised by an RN. Your home health nurse will provide direct care and will also teach your caregivers how to care for you when nursing is not available. Your nurse will observe, evaluate, and manage the care you receive at home to ensure it is adequate and that you’re making progress.
Examples of covered services you may receive from your home health nurse include giving IV medications, administering some injections, changing bandages, educating you on prescription medications, and teaching you about diabetes care, among other services as needed. In general, any task that can be administered safely by a non-medical person without the assistance of a nurse is not considered skilled nursing care and won’t be covered.
Physical Therapy, Occupational Therapy, Speech-Language Pathology Services
These services are covered when they have been determined to be necessary to improve or restore functions that have been impacted by your injury or illness, or they must be considered necessary maintenance therapies to keep your current condition from worsening. Moreover, the therapies must have enough complexity that they need to be performed by or under the supervision of licensed therapists. Exercises that you are able to perform yourself to improve your condition will not be covered.
Home Health Aide Services
If you are getting skilled care services (skilled nursing, physical therapy, speech-language pathology, or occupational therapy), Medicare will also cover part-time or intermittent home health aide services for personal care as long as these services are considered necessary to treat your injury or illness or to maintain your health. The maximum benefits of eight hours per day or 28 hours per week apply to both skilled services and home health aide services combined.
Medical Social Services
If your doctor believes that you need assistance with social and emotional issues that are interfering with your recovery, Medicare will cover medical social services, including counseling. To qualify for medical social services, you must also be receiving skilled care services (skilled nursing, physical therapy, speech-language pathology, or occupational therapy).
Any supplies you need as part of your home health care, such as bandages, are covered by Medicare as long as they are ordered by your doctor.
Durable Medical Equipment
Durable medical equipment, such as wheelchairs, walkers, crutches, etc., is covered by Medicare, but not under home health care benefits. In other words, you could still qualify for durable medical equipment coverage even if you don’t qualify for home health care coverage. Medicare typically pays 80% of the Medicare-approved amount for these items. However, your home health care agency will help arrange for the delivery of your durable medical equipment.
Services Not Covered
In general, Medicare will not pay for the following home health care services:
- Full-time skilled nursing care (care that goes over eight hours a day or 28 hours a week)
- Delivered meals
- Homemaker services, including shopping, cleaning, and laundry
- Personal care, including bathing, dressing, and toileting, if this is the only care you need
How to Find a Covered Home Health Agency
You can always ask your doctor for a referral to a home health agency that is covered by Medicare, but if you prefer to do your own research, Medicare offers a tool on its website that allows you to find and compare certified home health care agencies where you live. You’ll get basic information about each provider, including a quality rating and a patient rating. You are also able to filter by select criteria and save your favorites.
Once you have narrowed your choices down to three or four home health care agencies, use a checklist to make sure they offer the services you need and that they will be able to treat your specific illness or injury. If you have a Medicare Advantage plan from a private insurance company, you may be restricted to choosing an agency that is contracted with that insurer, so be sure to check on this as well.
You can only get care from one home health agency at a time, so if you’re dissatisfied with the care you’re getting from one agency, you’ll need to contact your physician to get a referral to a different one. Be sure to tell both agencies that you are switching home health care companies. You’re also welcome to choose the home health agency you want to work with even if you don’t have a referral. Your doctor should honor your choice.
Prior to receiving services from a home health care agency, they will provide you with information about how much of the fees will be covered by Medicare. You should also receive notifications on any services or items that won’t be covered by Medicare so that you can choose whether or not to accept them. This information should be provided to you in writing as well as explained to you verbally. Always ask your doctor if you’re not sure about coverage.
Medicare will cover home health care services as long as you meet the criteria outlined by the Centers for Medicare & Medicaid Services (CMS). If you are currently in need of home health care services or will be soon, we can help. Contact Parent Care today to schedule a free consultation.