Medicare covers home health care but with certain limitations. While the care coverage encompasses most health issues you may have, you must fulfill certain obligations.
This article will explain whether Medicare pays for home health care, how to qualify for home health care services covered by Medicare, and what is not covered.
What is Home Care and Home Health Care Services Under Medicare?
According to Medicare, home health care provides a broad spectrum of medical services delivered in the comfort of your home for various illnesses or injuries. This type of care is more cost-effective and convenient than the care received in hospitals or skilled nursing facilities while maintaining the same level of effectiveness.
Home health care can range from routine check-ups to more complex medical treatments and monitoring. It often involves a team approach, including various professionals such as nurses, therapists, and home health aides working together to deliver care directly to your home.
What Home Care Needs are NOT Covered by Medicare?
Medicare does not cover certain types of home care services. Understanding what is not included can help you plan better for your care needs. Here’s a more precise explanation of the services Medicare typically does not pay for:
1. Round-the-Clock Care
Medicare does not provide coverage for 24-hour home care. If you require continuous personal care throughout the day and night, you must find other funding options or care settings, such as your long-term care insurance.
2. Home Meal Delivery
Medicare won't pay for meal delivery to your home. This service is often essential for those who find it challenging to prepare meals due to health issues, but it will require separate private payment or assistance from community programs.
3. Homemaker Services
Medicare won't cover services that help with day-to-day tasks like shopping, cleaning, and laundry, which are not directly related to your medical care plan. If these tasks become challenging, alternative local resources or private payment will be necessary.
4. Custodial Care
Medicare does not cover ongoing custodial care if this is the only care you need. Custodial care includes assistance with daily living activities such as bathing, dressing, and restroom use. If skilled care is not also required, these essential but non-medical needs must be met through other means.
Important Note: Medicare covers only part-time or intermittent skilled nursing or therapy services. Medicare will not cover the cost if your condition requires more than this, such as full-time nursing care.
You can leave home for medical treatments or occasional short outings, such as attending religious services, without losing eligibility for home health benefits. Additionally, you can still receive home health care if you participate in an adult day care.
What Home Care Services are Covered by Medicare?
Medicare covers a range of services under home health, provided they are deemed medically necessary and prescribed by a certified health care provider. Below are the services covered by Medicare's home health care:
- Daily Skilled Nursing Care: Provided on a part-time or intermittent basis for needs such as:
- Wound Nursing Care: Skilled care and management for pressure sores, surgical or other serious wounds.
- Patient and Caregiver Education: Instruction on managing your condition at home, designed for a better understanding and independence in care.
- Intravenous or Nutrition Therapy: Administration of IV medications, fluids, or nutritional formulas.
- Injections: Administering necessary injections as prescribed by a healthcare provider.
- Monitoring of Serious Illness and Unstable Health Status: Regular monitoring to assess and respond to changes in a severe or unstable condition.
- Therapies:
- Physical Therapy: Exercises and treatments to restore movement and function affected by illness or injury.
- Occupational Therapy: Assistance and training in adapting to daily activities and work environments post-injury or illness.
- Speech-Language Pathology Services: Therapy to address speech, language, and swallowing issues.
- Medical Social Services: Services addressing social and emotional concerns related to illness or recovery, such as counseling or locating community resources.
- Home Health Aide Services: Provided part-time or intermittently, but only in conjunction with skilled services like nursing or therapy. These include assistance with:
- Basic Personal Tasks: Help with bathing, dressing, grooming, and toileting.
- Household Tasks Related to Health Care: Assistance with tasks like changing bed linens or managing diet.
- Additional Services:
- Injectable Osteoporosis Drugs: For women, as prescribed.
- Durable Medical Equipment (DME): Such as wheelchairs or walkers needed for mobility.
- Medical Supplies: Like wound dressings and catheters used at home.
- Disposable Negative Pressure Wound Therapy Devices: Equipment used for wound care at home.
Do you think you qualify for Medicare-covered home health care? If you're not sure, the section below should guide you.
How to Qualify for Medicare Home Health Benefits
Medicare provides coverage for a wide range of health services through Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance), provided certain conditions are met.
To qualify, you must satisfy the following criteria:
- Part-time or Intermittent Skilled Nursing Care: You require skilled nursing services or therapeutic care part-time, generally meaning less than 8 hours a day and 28 or fewer hours each week (up to 35 hours in some exceptions).
- Homebound Status: You are considered homebound if:
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- Mobility Limitations: You require the assistance of a device (such as a wheelchair, cane, walker, or crutches), special transportation, or another person to leave your home due to illness or injury.
- Medical Advisement: Your medical condition makes it inadvisable to leave your home.
- Considerable Effort: Leaving home takes a significant effort due to your condition.
Below is a more detailed step to qualify for home health offered by Medicare:
1. Consult with Your Doctor
The process begins with a consultation with your physician or a qualified healthcare provider. This is crucial as Medicare requires a doctor's certification that you need one or more of the following services: skilled nursing care, physical therapy, speech-language pathology services, or continued occupational therapy.
2. Doctor’s Certification of Homebound Status
Your doctor must certify that you are homebound. Being homebound means that leaving home is a major effort. You may be considered homebound if you require the aid of supportive devices, the special assistance of another person or if leaving your home is medically inadvisable because of your condition.
3. Face-to-Face Encounter
Medicare requires a face-to-face encounter with a doctor or specific healthcare provider. This encounter must occur 90 days before or 30 days after the start of home health care. During this encounter, the provider must confirm that you need home health services for the diagnosis discussed during the visit.
4. Obtain a Physician’s Order
The treatment plan should include the services you need, which your physician must order. This plan outlines what services you need, how often they will be provided, and the duration of the treatment. The care plan must be reviewed and renewed regularly, typically every 60 days.
5. Use a Medicare-Certified Home Health Agency
For Medicare to cover your home health services, the services must be provided by a Medicare-certified home health agency (HHA). Your doctor or hospital should be able to recommend Medicare-certified care agencies.
6. Undergo Periodic Reviews
Your doctor must review and recertify your home health care needs periodically. This typically happens every 60 days. The recertification must confirm that you remain homebound and need skilled care.
7. Meeting Specific Service Requirements
For ongoing eligible home health services, the services provided must be specific and limited to those that are reasonable and necessary for treating your illness or injury. Skilled nursing care, for instance, must be part-time or intermittent and not full-time.
What are the Limitations and Out-of-Pocket Costs of Medicare Coverage?
While Medicare pays for home care, there are certain limitations to the service, including:
- Scope of Services: Medicare will cover part-time home health services a doctor prescribes. However, you'll need more than just healthcare services as an older adult. You may need a caregiver, home modification services, transportation solutions, and legal and financial planning advice. Medicare doesn't cover those.
- Duration and Frequency: Coverage is typically limited to part-time or intermittent care. Full-time care or services beyond the approved frequency are not covered under standard Medicare.
- Provider Restrictions: Only care provided by Medicare-certified home health care agencies is covered. Using providers outside this network does not qualify for Medicare reimbursement.
- Care Plan Renewal: Physician-certified care plans must be renewed every 60 days. Failure to renew or update them according to the patient’s current health status may result in a lapse of coverage.
- Homebound Requirement: Medicare requires you to be homebound to qualify for home health services, which means your ability to leave home is majorly restricted due to your health condition.
While the process to become eligible for home health services by Medicare may be straightforward, the services are limited. If you want to enjoy more comprehensive care as you age, you may need more support from other sources.
Medicare Advantage (Part C) Considerations
- Enhanced Benefits: Many Medicare Advantage plans offer additional benefits beyond what Original Medicare covers. This might include extended home health services and coverage for services not covered by Medicare.
- Network Restrictions: Medicare Advantage plans often have network restrictions; receiving services from providers outside this network may lead to higher out-of-pocket costs or lack of coverage.
- Cost Variations: Medicare Advantage plans usually have different cost structures from Original Medicare, including set service copayments. They also typically have an out-of-pocket maximum, which can provide financial protection by capping expenses each year.
- Plan-Specific Rules: Some Medicare Advantage plans may require pre-authorization for home health services or referrals from a primary care doctor, which are not stipulations under Original Medicare.
What Happens When You're Certified Eligible for Medicare Benefits?
Once you're certified as eligible for Medicare benefits, a few crucial steps help you access the healthcare services you need:
- Receive Your Medicare Card: Arrives by mail and is required for all healthcare visits and pharmacy needs.
- Coverage Starts: Begins on the first day of the month when you turn 65 or the month before that if your birthday is on the first.
- Choose Additional Coverage: Options include Medicare Advantage (Part C), prescription drug coverage (Part D), or Medicare Supplement Insurance (Medigap) for extra services like dental and vision.
- Initial Health Exam: "Welcome to Medicare" visit within your first year of Part B enrollment to set up preventive care plans.
- Annual Check-Ups: A yearly wellness visit to update your personalized prevention plan.
- Using Your Benefits: Utilize your benefits for various healthcare needs and understand any associated costs.
Medicare will regularly send updates about new benefits, changes in coverage, and reminders for preventive screenings. Keeping informed through these communications helps you maximize your benefits and stay proactive about your health care.
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