Does Medicare cover home health care? You’ve undoubtedly put “what does Medicare cover for home health care in America?” into Google and then quickly closed the tab. The sheer number of material and level of detail can rapidly become confusing and overwhelming (and you’ll almost certainly wind up with more questions than when you started). We’ve broken down this crucial subject into a series of commonly asked questions, covering what home health services are available, what services aren’t covered, who is qualified, and how much it will cost.
What is home health care?
Following an injury or illness, home health care encompasses a wide range of health services delivered in the comfort of your own home. It is an excellent alternative for many people since it is cost-efficient, convenient, and just as effective as care received in a hospital or clinic.
Home health care, also known as home-care, supportive care, or in-home care, is offered by a competent professional in the comfort of your own home rather than in a clinic or other group setting.
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What are the options for home health care?
There are a variety of home health services accessible under Medicare Part A (hospital insurance) and Medicare Part B (medical insurance), including:
- Physical therapy;
- Occupational therapy services;
- Services in speech-language pathology;
- Skilled nursing care on a part-time basis;
- Social medical services;
- Services of a part-time (intermittent) home health assistant for personal hands-on care;
- Osteoporosis drugs (injectables for women).
A home health care agency will usually organise the services based on what your doctor has recommended for you.
What isn’t covered?
Home health care is covered by Medicare, but not round-the-clock care (24 hours a day) or meal deliveries. Homemaker services (such as cleaning and washing) and personal care (such as bathing and dressing) are also not covered if it is the only care you require.
Who is eligible for in-home care?
You must have Medicare Part A and/or Part B in order to use the available home health care services. You must also fulfil the following requirements:
- You must be under the supervision of a licenced physician, and your case must be examined on a regular basis.
- If you require competent nursing care or therapy, your doctor must confirm this. For a limited time, you must require physical, occupational, or speech treatment.
- You must be housebound, which means that you are unable to leave your home without assistance.
- You must receive a doctor’s certification that you are housebound after a documented visit with your doctor no more than 90 days prior to or 30 days after your home health care begins.
- You should only need expert nursing on a part-time basis (excluding drawing blood).
- Medicare certification is required for the home health agency providing care.
- You should only need expert nursing on a part-time basis (excluding drawing blood).
- Medicare certification is required for the home health agency providing care.
If you require more than intermittent skilled nursing care, you will not be eligible for home health benefits. You may, however, leave your house for brief outings such as religious services or medical treatment. If you go to adult daycare, you will still be eligible.
Visit Medicare’s website to learn more about who is eligible for services.
How much does Medicare cover for home health care?
You don’t have to pay anything for home health services if you have original Medicare. For durable medical equipment, there is a co-pay of 20% of the Medicare-approved amount (such as wheelchairs, hospital beds, crutches, walkers, kidney machines, ventilators, oxygen, monitors, and pressure mattresses).
Before beginning home health care, consult with your agency to determine what costs will be spent and which will be paid by Medicare. They’ll also let you know if there are any services that Medicare doesn’t cover. This should be stated both verbally and in writing, and you will be given a “Advance Beneficiary Notice” before receiving any non-Medicare treatments.
Your home health agency may submit a pre-claim review request to Medicare in select states (including Florida, Michigan, Illinois, Massachusetts, and Texas). This is beneficial to both you and the agency since you will know whether Medicare will fund the services.
The amount you repay for non-Medicare covered services is determined by the following factors:
- Any other health-related insurance you may have;
- The fees charged by your physician;
- If your doctor agrees to work with you;
- The type of treatment facility;
- Where you get your tests or services.
In rare situations, your doctor may propose a treatment plan that needs more frequent treatments than Medicare covers, or therapies that are not covered. You will be responsible for the charges if this occurs, so ask questions to understand why they are being advised and what costs you would have to pay out of pocket.
Is skilled nursing care covered?
Intermittent (or part-time) nursing services are covered by Medicare. This means that nursing care is provided for no more than seven days per week or for no more than eight hours per day, up to a maximum of 21 days. In some situations, Medicare will extend the time limit if your doctor can accurately predict when your care would conclude.
In most cases, skilled nursing services are used to treat a sickness or support a patient in recovering from an injury. To give the medical therapy you require, the nurse must be licensed (such as wound dressing, injections, and catheter changes).
What home health services are provided by aides?
If you require assistance with daily activities such as dressing, bathing, or going to the bathroom as a result of an injury or illness, home health aides can help. Medicare will only pay for them if you also receive professional nursing or therapy.
When is physical, occupational, or speech therapy covered by Medicare?
When physical therapy is used to help a patient regain strength or mobility following an illness or injury, Medicare will pay for it. The same is true for occupational therapy, which aims to restore functionality, and speech therapy, which aims to teach patients how to communicate again.
The services will only be covered if they are projected to improve the situation within a reasonable time frame. Furthermore, the frequency, duration, and a number of services must be acceptable, and they must be offered by a licenced therapist. To be eligible for the services, your condition must meet one of the following criteria:
- Expect things to get better.
- Require a professional therapist’s maintenance programme, or
- Maintenance will necessitate the services of a qualified therapist.
Following an illness or accident, professional therapists will restore or increase your capacity to perform basic daily tasks, communicate, and even walk. They may also assist prevent a condition from worsening, but they will only be covered if the services are used to treat your disease specifically, safely, and efficiently.
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What durable medical equipment is covered by Medicare?
If it is judged medically necessary and has been prescribed by a doctor for use at home, Medicare will cover the cost of durable medical equipment. The following items are included in the list of durable medical equipment that is covered:
- Wheelchairs (manual or electric);
- Canes or walkers are both acceptable options.
- Beds in hospitals;
- Oxygen;
- Nebulizers;
- Blood sugar monitors.
You will be responsible for the remaining deductible under Medicare Part B, as well as 20% of the Medicare-approved value for the equipment.
What are medical social services?
These are medically prescribed treatments that assist patients in dealing with the emotional repercussions of illness or disease. In-home counselling by a licenced therapist or social worker is an example of medical social services that Medicare covers. Keep in mind that Medicare only pays for these services if you receive competent nursing care at home. If you require assistance, they can also assist you in locating community services.
How has COVID-19 affected home health services?
During the COVID-19 epidemic, Medicare has allowed nurse practitioners, clinical nurse specialists, and physician assistants to offer home health care without the need for a physician’s certification.
If you have Medicare and need home health care, there are a number of options available to assist you as you recover from an injury or illness. To find out if you’re qualified for home health care and what Medicare covers, call Medicare and ask for a referral to a registered doctor in your region, or schedule an appointment with your doctor to discuss your options.
