Home health care and home care are often mixed up due to the similarity in their names. Home care refers to privately paid caregivers who can provide non-medical care to clients. Home health care is a benefit covered by Medicare (and other health insurance) for patients who qualify.
Jump ahead to these sections:
- Will Medicare Pay for Home Health Care Costs?
- What Home Health Care Services Will Medicare Cover?
- What Home Health Care Services Will Medicare NOT Cover?
- How Do You Qualify for Home Health Care Coverage?
- How Do You Get Medicare to Pay for These Costs?
The value of home health care can not be overstated. The home health benefit can offer support for patients recovering from an illness or accident who want the opportunity to maximize their ability to function as independently as possible. You can use home health following a rehab stay or hospitalization. You can receive home health care in assisted living or your home.
If you have Medicare, either original Medicare or a Medicare Advantage (MA) plan, and meet qualifying criteria, Medicare will pay for home health costs. Understanding how, when, and for how long Medicare pays for home health will help you take full advantage of the services that home health care has to offer.
Will Medicare Pay for Home Health Care Costs?
Medicare will pay for home health care costs if you meet all criteria for participation. Original Medicare allows you to go to any home health care agency that is a Medicare contracted provider. The agency should also tell you if Medicare doesn’t cover any items or services and how much you'll have to pay.
This should be explained by both telling you and in writing. Before giving you services and supplies that Medicare doesn’t cover, the home health agency should provide you with the Advance Beneficiary Notice (ABN).
MA plans, however, have restrictions on which home health agencies they will pay for, and there might be co-pays or deductibles for specific services and durable medical equipment.
Another essential feature of home health services and Medicare payment is the certification period. A physician or other Medicare-designated healthcare provider must certify that you need home health.
After 60 days, if you continue to need home health, the ordering physician must recertify that you require the services. If you don’t make progress and meet goals or refuse services during the 60 days, the home health agency may discharge you from home health.
What Home Health Care Services Will Medicare Cover?
Medicare will cover a wide range of healthcare services under the home health care benefit, but you may not need all of them depending on the condition that qualified you to begin with. However, you have to have some need for professional services to be eligible for home health care services.
Part-time or intermittent nursing services
Part-time or intermittent nursing is nursing care you need less than seven days a week and less than eight hours a day (with some exceptions). Nursing services can include injections (and teaching you to self-inject), tube feedings, catheter changes, assessing your condition, developing and managing your care plan, and wound care.
Skilled therapy services
Skilled therapy services include physical, speech, and occupational therapy:
- Physical therapy includes gait, balance, and strength training and other assistance regaining the ability to walk, transfer, or perform other activities of daily living.
- Occupational therapy helps you regain the ability to perform daily activities by yourself, such as eating and putting on clothes, planning meals, and engaging in work or hobbies.
- Speech-language pathology helps patients with speaking and swallowing. A good example of speech therapy is following a stroke when someone loses the ability to communicate. Speech pathologists can also suggest and refer to swallow testing for people at risk of choking. They can recommend specific diets to reduce the risk of aspiration.
Home health aides
Home health aides are a covered service under Medicare and a vital part of the care team. Aides assist patients with bathing, dressing, toileting, transferring, and reinforcing therapy goals. They can also help patients with orthopedic or prosthetic devices.
Home health aides usually assist for about one hour each day up to three days a week. Any care you or a loved one needs beyond that would have to be provided by someone else.
Social services
Social workers are licensed professionals who help patients and their families adjust to and cope with emotional problems resulting from injury or illness. They may refer you or your family members for counseling. Social workers also refer patients and families to outside resources.
Medical supplies
Medicare may pay for medical supplies such as wound care, bandages, and catheter supplies. Examples of durable medical equipment are wheelchairs, walkers, oxygen, and other devices necessary for treatment and recovery. There may be co-pays for this type of equipment. In some cases, you may be able to rent equipment rather than purchase it.
What Home Health Care Services Will Medicare NOT Cover?
There are services Medicare will not pay for, which may come as a surprise to some families. If your loved one needs some of the care that Medicare will not cover, you will need to consider family caregiving or private-pay caregivers. Medicare will not cover the following under the home health care benefit:
- 24-hour-a-day care at home from nurses, aides, or other home health professionals
- Meals delivered to your home
- Home healthcare aide, unless it’s a skilled service like nursing or physical therapy
- Homemaker services like shopping, cleaning, and laundry
- Co-pays or costs for some medical supplies and other equipment.
How Do You Qualify for Home Health Care Coverage?
For Medicare to qualify you for home health coverage, you must meet specific criteria. If you’re in doubt about qualifying, contact your physician first to tell you whether they are willing to write an order for services. If your physician is willing to certify that you need home health care, you can contact the home health agency of your choice and proceed from there. Here are the qualifying criteria:
- The amount, frequency, and period of time of the services need to be reasonable. In other words, there’s the expectation that your condition will improve in a specific time period. If your condition is so fragile that home health is not adequate to help you meet goals, you may not qualify.
- You must be under the care of a doctor, and if you haven’t seen your physician in a long time, they may require a face-to-face visit to authorize home health.
- Your doctor must certify that you need one or more of these: intermittent skilled nursing care, physical and/or speech therapy, and occupational therapy.
- To qualify for home health services under Medicare, you must be home-bound. Being home-bound means that you need significant assistance to leave your home, such as a wheelchair or walker or another person.
- The agency you choose to get services from must be Medicare-certified.
- If you require more than intermittent care, which means fewer than seven days a week and less than eight hours a day, you do not qualify for home health under Medicare.
How Do You Get Medicare to Pay for These Costs?
As the recipient of home health services with a Medicare provider, you would not typically need to get Medicare to pay for costs. Medicare pays your Medicare-certified home health agency for the covered services you get during a 30-day period of care.
You can have more than one 30-day period of care if your physician continues to certify the need for care based on your goals and progress. The home health agency takes care of all billing to get Medicare reimbursement.
The reasons a homecare agency may discharge you from service could be because you don’t meet your goals, or you do meet your goals and no longer require skilled services. Any potential co-payments should be discussed with the homecare agency you choose. Also, if you have a Medicare Advantage plan, you will want to call your insurance plan to discuss any co-pays or speak with the home health agency you select.
Medicare Payment for Home Health Care Costs
Although it’s a beneficial healthcare program, Medicare can be complicated to understand. Benefits through medicare are numerous but require an understanding of the criteria for participation. This is especially true of Medicare Advantage plans. Home healthcare costs are covered under Medicare if you follow the rules for participation. Take full advantage of home health care on your way to recovery and wellness.