Most seniors want to stay in their home as they age, but what happens when they need more care? Medicare does pay for some home health care services in specific circumstances for those who meet the criteria. Here’s what your clients need to know about Medicare’s home health care coverage.

How To Qualify

In order to be eligible for home health benefits an individual must meet all of the following criteria:

  • A doctor must certify they are homebound

This means they are unable to leave home without the assistance of another person, or assistive devices such as a walker or wheelchair, or they need special transportation due to their illness or injury. Leaving home for doctors’ appointments, religious services, to attend adult day care, or occasional trips to the hair salon or barber shop are acceptable while considered homebound.

  • The home health agency providing care must be approved by Medicare

Medicare’s search and comparison tool can help locate certified home health agencies in a specific area or zip code. The tool also provides quality ratings that measure the agency’s performance as well as patient surveys that ask whether a patient would recommend that agency to someone else. Individuals who have coverage through a Medicare Advantage plan may also need to find a home health agency in their plan’s network. They should talk with their plan about any special requirements before choosing an agency.

  • Have certification from a doctor

This certification must show the individual needs intermittent skilled nursing care, or intermittent physical therapy, occupational therapy or speech language therapy related to their illness or injury. This certification requires a face-to-face visit with a doctor (or other medical professional working directly with the doctor such as a nurse practitioner) no more than 90 days before or 30 days after the start of home health care

  • Be under a plan of care established by a doctor

When establishing a plan of care the doctor must document the specific care needed and how often, the required supplies and the anticipated results. The plan must be reviewed and recertified every 60 days.

Which Services Are Covered

  • Skilled Nursing

Medically necessary part time or intermittent skilled nursing care for services such as changing wound dressings or assisting with feeding tubes. This care can be provided up to 8 hours a day with a maximum of 28 hours per week. More frequent care may be approved for a short period of time if the doctor determines it’s necessary.

  • 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 individual is also receiving skilled nursing care or therapy.

  • Physical, Occupational, and Speech Language Therapy

Professional therapy to restore or improve the ability to walk, perform everyday tasks or speak after an illness or injury

  • Medical Social Services

Counseling for social or emotional concerns related to the illness or injury if the individual is also receiving skilled nursing care.

  • DME Supplies

Some DME supplies such as catheters and wound dressings related to the illness or injury are covered if provided by the home health agency. In some cases, a walker or wheelchair may be covered.

What is Not Covered

  • 24/7 care at home
  • Custodial or personal care

Such as assistance with the activities of daily living i.e., dressing, feeding, bathing and toileting if this is the only care needed and there is no other medical issue requiring care.

  • Household help and errands

Such as help with cleaning, laundry, and grocery shopping.

  • Home delivered meals

While not covered by Original Medicare, some Medicare Advantage plans may offer a limited number of home delivered meals after a hospital stay.

What Will it Cost

If all the requirements are met Original Medicare will pay 100% for home health services after the Part B deductible is met and 80% of DME of costs. If the individual has a Medicare Supplement plan the remaining 20% of DME costs will be covered. Individuals with a Medicare Advantage plan will have out of pocket costs based on their specific plan. They should speak with their insurance carrier for detailed benefits.

Prior to providing care, the home health agency should advise what services are not covered by Medicare and the cost of those services. This should be provided both verbally and in writing. Individuals receiving services from a home health agency in Texas, Florida, Illinois, Massachusetts, or Michigan may be affected by a Medicare demonstration program. The individual seeking care or their home health agency may submit a request for pre-claim review of coverage to Medicare. This will let them know earlier in the process if the services meet Medicare’s requirements for coverage.

Additional Resources are Available

Local and state programs may offer additional assistance with senior services such as adult day care, meal delivery, transportation, DME equipment and care giver resources.

If you have questions the experienced team at PTT Financial is here to help. Contact us today.