Most seniors want to stay in their homes as they age. This likely includes many of your clients. But what happens if it becomes more difficult for them to get out of their house for medical care? They might qualify to receive Medicare covered home health services if they meet the criteria. Here’s what you and your clients need to know.
How to Qualify
There are several criteria which must be met in order to qualify for Medicare covered home health services:
- Your doctor must certify that you are homebound. This means you are unable to leave your home without the help of another person, or without the use of mobility aids such as a cane, crutches, walker, or wheelchair. You may require special transportation such as a wheelchair van due to an illness or injury.
- Your certification must show that you need intermittent skilled nursing care, physical therapy, occupational therapy, or speech therapy due to an illness or injury. The certification must be done in a face to face visit with your doctor no more than 90 days before or 30 days after the start of your home health care services.
- Your doctor must establish a plan of care which documents the specific care you need and how often you need to receive it. The plan of care will also specify any needed medical supplies and the anticipated results of your care. The plan of care must be reviewed and recertified every 60 days.
- The home health agency providing your care must be approved by Medicare. Your doctors office might be able to provide a list of home health agencies in your area or you can use Medicare’s Find a Provider tool to help locate agencies in your zip code. The Find a Provider tool also provides ratings on the agency’s performance. If you have a Medicare Advantage plan, you may need to use an agency in your plan’s network. You should speak with your insurance carrier about any special requirements before choosing an agency.
Coverage is not dependent on a specific diagnosis or condition. Some examples of individuals who would qualify for homebound status are:
- An individual who has just returned home from a hospital stay after surgery and may be restricted to limited activities due to weakness or pain.
- An individual who is paralyzed by a stroke and requires a wheelchair or crutches.
- An individual who is blind or has dementia and needs the assistance of another person to leave home.
What Services are Covered
- Skilled Nursing – Medicare limits this care to up to 8 hours per day and a maximum of 28 hours per week. Medicare may approve up to 35 hours of care per week if the patient’s doctor says it’s necessary. Skilled nursing care can include services such as changing bandages or assisting with feeding tubes.
- Home Health Aide – to assist with personal activities such as bathing, dressing, or toileting only if this help is needed due to an illness or injury. Medicare will only cover these services if the patient is also receiving skilled nursing care or therapy.
- Physical, Occupational, and Speech Therapy – is covered to help restore or improve the patient’s ability to walk, perform everyday tasks or speak after an illness or injury.
- Durable Medical Equipment (DME) – these are medical supplies included in the patient’s plan of care such as catheters, ostomy bags, and wound dressings related to the patient’s illness or injury. In some cases, a walker or wheelchair may be covered. These supplies must be received from the home health agency certified to provide the patient’s care.
- Counseling – for social or emotional concerns related to the illness or injury if the patient is also receiving skilled nursing care.
What Is Not Covered
- Medications
- Transportation
- 24/7 home care
- Custodial or personal care such as help with mobility issues, getting dressed, eating, bathing, and toileting if this is the only care needed and there is no other medical issue requiring care.
- Help with household chores and errands
- Home delivered meals (although some Medicare Advantage plans may offer a limited number of home delivered meals after a hospital stay)
When Can You Leave Your Home if You Are Considered Homebound
Even if your clients leave the house occasionally, they may meet Medicare’s definition of “homebound,” so encourage them to seek this status.
Here’s how it works. If you have been certified as homebound, Medicare does make exceptions for some situations and events that require you to leave your home if they are infrequent. These include leaving your home for medical appointments, to attend adult day care, religious services, occasional trips to the barber or hair salon, and special non-medical events such as funerals, weddings, reunions, and graduations. Attending these events does not jeopardize your homebound status.
You may also be allowed to drive under some limited circumstances, for example, if you have no other option than to drive yourself to a doctor’s appointment. The effort to drive must be considered difficult and taxing.
What Medicare Covers
What Medicare covers will depend on the type of Medicare coverage you have.
Original Medicare
Original Medicare will pay 100% for home health services after the Part B deductible is met. It will cover 80% of DME costs. If the individual has a Medicare Supplement plan, it may cover some or all of the remaining 20%.
Medicare Advantage
Individuals with a Medicare Advantage plan will have out of pocket costs based on their specific plan. There may also be some additional benefits not offered by Original Medicare. Enrollees should speak with their insurance carrier for detailed benefits.
The home health agency providing care should explain how much Medicare will pay. They should also explain in advance, both in writing and verbally, what items and services Medicare will not pay for and how much the patient will have to pay out of pocket.
Additional Resources May Be Available
If your clients are seeking homebound status, they may need additional support. There may be local and state programs that provide additional assistance for services such as home delivered meals, transportation, adult day care, and DME supplies. The individual’s local church, senior center, county Department of Social Services, or U.S. Department of Health and Human Services can help them locate these resources.
Helping your clients navigation Medicare’s homebound status rules is one way to meet their needs and show your value as a trusted agent. At PTT Financial, we believe in supporting our agents so they can educate their clients and make more sales. Learn more.