Medicare and Home Health Care
This is the official U.S. government booklet about Medicare home health care benefits for people with Original Medicare. This booklet has important information about the following:
- Who is eligible
- What services are covered
- How to find and compare home health agencies
- Your Medicare rights
Many health care treatments that were once offered only in a hospital or a doctor’s office can now be done in your home. Home health are is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility. In general, the goal of home health care is to provide treatment for an illness or injury. Home health care helps you get better, regain your independence, and become as self-sufficient as possible.
Medicare pays for you to get certain health care services in your home if you meet certain eligibility criteria and if the services are considered reasonable and necessary for the treatment of your illness or injury. This is known as the Medicare home health benefit.
If you get your Medicare benefits through a Medicare health plan (not Original Medicare) check your plan’s membership materials, and contact the plan for details about how the plan provides your Medicare-covered home health benefits.
If you have Medicare, you can use your home health benefits if you meet all the following conditions:
1. You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.
2. You must need, and a doctor must certify that you need, one or more of the following.
■ Intermittent skilled nursing care
■ Physical therapy
■ Speech-language pathology services
■ Continued occupational therapy
3. The home health agency caring for you must be approved by Medicare (Medicare-certified).
4. You must be homebound, and a doctor must certify that you’re homebound. To be homebound means the following:
■ Leaving your home isn’t recommended because of your condition.
■ Your condition keeps you from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person).
■ Leaving home takes a considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as
attending religious services. You can still get home health care if you attend adult day care, but you would get the home care services in your home.
What Medicare covers
If you’re eligible for Medicare-covered home health care, Medicare covers the following services if they’re reasonable and necessary for the treatment of your illness or injury:
■ Skilled nursing care. Skilled nursing services are covered when they’re given on a part-time or intermittent basis. In order for skilled nursing care to be covered by the Medicare home health benefit, your care must be necessary and ordered by your doctor for your specific condition. You must not need full time nursing care and you must be homebound. Skilled nursing services are given by either a registered nurse (RN) or a licensed practical nurse (LPN). If you get services from a LPN, your care will be supervised by a RN. Home health nurses provide direct care and teach you and your caregivers about your care. They also manage, observe, and evaluate 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. Any service that could be done safely by a non-medical person (or by yourself) without the supervision of a nurse, isn’t skilled nursing care. Home health aide services may be covered when given on a part-time or intermittent basis if needed as support services for skilled nursing care. Home health aide services must be part of the care for your illness or injury. Medicare doesn’t cover home health aide services unless you’re also getting skilled care such as nursing care or other physical therapy, occupational therapy, or speech-language pathology services from the home health agency.
■ Physical therapy, occupational therapy, and speech-language pathology services. Medicare uses the following criteria to assess whether these therapy services are reasonable and necessary in the home setting:
1. The therapy services must be a specific, safe, and effective treatment for your condition.
2. The therapy services must be complex or your condition must require services that can safely and effectively be performed only by qualified therapists. Section 1: Medicare Coverage of Home Health Care 9
3. One of the three following conditions must exist:
■ It’s expected that your condition will improve in a reasonable and generally-predictable period of time.
■ Your condition requires a skilled therapist to safely and effectively establish a maintenance program.
■ Your condition requires a skilled therapist to safely and effectively perform maintenance therapy.
4. The amount, frequency, and duration of the services must be reasonable.
What isn’t covered?
Below are some examples of what Medicare doesn’t pay for:
■ 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. See page 19.
■ Personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need. Talk to your doctor or the home health agency if you have questions
about whether certain services are covered. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
What you have to pay
You may be billed for the following:
■ Medical services and supplies that Medicare doesn’t pay for when you agree to pay out of pocket for them. The home health agency should give you a notice called the Home Health Advance Beneficiary Notice (HHABN) before giving you services and supplies that Medicare doesn’t cover.
■ 20% of the Medicare-approved amount for Medicare-covered medical equipment such as wheelchairs, walkers, and oxygen equipment. Medicare Coverage of Home Health
[button type=”link” link=”http://www.medicare.gov/pubs/pdf/10969.pdf” size=”btn-large” variation=”btn-success” block=”btn-block” target=”blank”]View full article! [/button]