Home Health

Does Medicare Cover Home Health?

Yes, Medicare does cover home health care services in certain circumstances. Medicare’s home health benefit covers a wide range of medical services provided in the home setting for beneficiaries who are eligible and meet specific criteria.

When Does Medicare Pay for Home Health?

Specific criteria to receive Medicare-covered home health include:

• You must be under the care of a doctor: Your doctor must create a plan of care for you, certifying that you need medical care at home and that you’re homebound.
• Your doctor must certify that you’re in need of skilled care: Medicare does not cover custodial care (long-term) or assistance with activities of daily living, such as bathing and dressing, unless it is part of the skilled services being provided.
• You must be homebound: Medicare defines homebound as being unable to leave your home without considerable effort, and you require help from another person or assistive devices such as crutches, canes, wheelchairs, or walkers.
• You need skilled nursing care, physical, speech, or occupational therapy on an intermittent basis: “Intermittent” generally mean part-time, less than 8 hours per day or less than 28 hours each week (35 hours per week in very circumstances). Medicare will cover services such as intermittent skilled nursing care, physical therapy, speech-language pathology services, occupational therapy, and medical social services.
• You must receive care from a Medicare-certified home health agency: Medicare only covers home health services provided by agencies approved by Medicare.
• Your care must be reasonable and necessary for your condition: Medicare will only cover services that are deemed reasonable and necessary for the treatment of your illness or injury.
• You must have a Care Plan: Your doctor must establish a plan of care for you, outlining the necessary services and how often you need them. The home health agency will work with your doctor to finalize the plan of care and submit it to Medicare for approval.

It’s important to note that these requirements apply specifically to Medicare coverage for home healthcare services. Other insurance plans or programs may have different eligibility criteria. If you’re unsure about your eligibility or have questions about coverage, it’s recommended to consult with your doctor or a representative from a Medicare-certified home health agency.

If you believe you or a loved one may qualify for Medicare-covered home health care services, it’s advisable to speak with your doctor or healthcare provider to discuss your needs and determine the appropriate course of action.

What Services Does Home Health Cover?

It is important to understand that services covered under “Home Health” must be part of an active treatment plan to treat an illness or injury. These services may include:

• Skilled Nursing Care: This includes services provided by registered nurses (RNs) or licensed practical nurses (LPNs), such as wound care, medication management, injections, and monitoring of health conditions.

• Physical Therapy: Home health physical therapists can provide exercises, treatments, and strategies to help you regain or improve your strength, mobility, balance, and overall function.

• Occupational Therapy: Occupational therapists can help you with activities of daily living (ADLs), such as bathing, dressing, and meal preparation, as well as with adaptive techniques and equipment to improve independence and safety in your home environment.

• Speech-Language Pathology Services: Speech-language pathologists can assist with speech and language disorders, swallowing difficulties, cognitive-communication impairments, and other related issues.

• Medical Social Services: Home health agencies may provide social workers to help you and your family with emotional support, counseling, community resource referrals, and assistance with healthcare-related issues.

• Home Health Aide Services: While not covered under Medicare as standalone services, home health aides may be provided as part of a Medicare-covered plan of care to assist with personal care tasks, such as bathing, dressing, grooming, and light housekeeping.

• Medical Supplies and Equipment: Medicare may cover certain medical supplies and equipment needed for your care at home, such as wound dressings, catheters, oxygen equipment, and mobility devices. You may have a copay or coinsurance for these supplies.

How Much Does Medicare Pay for Home Health?

The amount that Medicare pays for home health services can vary depending on several factors, including the specific services provided, the length of time care is needed, and any co-payments or deductibles that apply. Generally, Medicare covers 100% of the approved amount for covered home health services if you meet all the eligibility criteria and use a Medicare-certified home health agency.

Here are some key points regarding Medicare coverage for home health services:

• Medicare Part A and Part B Coverage: Home health services are covered under both Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Part A typically covers home health services you receive after a hospital stay, while Part B covers medically necessary services you receive at home.
• No Cost for Eligible Services: If you qualify for Medicare-covered home health services, you typically won’t have to pay anything out-of-pocket for those services. This includes services like skilled nursing care, physical therapy, occupational therapy, speech-language pathology services, and medical social services. Check with your specific Medicare Plan to see if there are limitations or restrictions.
• Co-Payments or Deductibles: While Original Medicare covers the cost of eligible home health services, you may still be responsible for certain costs, such as co-payments or deductibles. These costs can vary depending on your specific Medicare plan and any supplemental insurance you may have.

For example: Your Medicare Advantage Plan may cover your eligible Home Health needs 100% as long as you remain in-network. If you choose a home health agency that is out of network, you may be responsible for some or all of the costs associated with home health.

• Plan Limitations and Coverage Details: While Medicare covers many home health services, there may be limitations and specific requirements for coverage. It’s essential to review your Medicare plan’s coverage details and consult with your healthcare provider or the home health agency to understand what services are covered and any potential costs.

It’s advisable to check with Medicare or your Medicare-certified home health agency to understand the specific coverage details and any potential costs associated with home health services in your situation.

Do Medicare Advantage Plans Cover Home Health?

Medicare Advantage plans, also known as Medicare Part C plans, are offered by private insurance companies approved by Medicare. These plans are required to provide at least the same level of coverage as Original Medicare (Medicare Part A and Part B), but they may also offer additional benefits beyond what Original Medicare covers, such as coverage for in-home health services.

Some Medicare Advantage plans may offer coverage for in-home health services, including services like skilled nursing care, physical therapy, occupational therapy, speech-language pathology services, and medical social services. However, the specific coverage and cost-sharing details can vary depending on the plan you choose.

If you’re interested in Medicare Advantage coverage for in-home health services, it’s essential to carefully review the details of each plan you’re considering. Look for information about the types of in-home services covered, any limitations or restrictions on coverage, and any cost-sharing requirements such as copayments or coinsurance.

You can obtain this information by reviewing the plan’s Summary of Benefits, Evidence of Coverage, contacting the insurance company directly, or speaking with a licensed insurance agent who can help you compare different Medicare Advantage plans and find one that meets your needs, including coverage for in-home health services.

I Am Approved For Home Health. What’s next?

Once you are approved for Home Health, there are a few additional things to keep in mind:

• Schedule Services: Once Medicare approves the plan of care, the home health agency can begin providing services according to the approved plan.
• Review and Renew: Medicare will periodically review your plan of care to ensure that you still need home health services. Your doctor may need to update the plan of care if your needs change. If your condition requires continued care, your doctor can recertify your eligibility for additional periods of care.
• Pay Any Required Costs: While Medicare covers the cost of eligible home health services, you may still be responsible for certain costs, such as co-payments or deductibles. These costs can vary depending on your specific Medicare Plan and any supplemental insurance you may have.

It’s essential to check with Medicare or a Medicare-certified home health agency to understand specific coverage details and eligibility requirements as they can sometimes vary based on individual circumstances and changes in Medicare regulations.

Is respite care covered under home health?

Respite care, which provides temporary relief to caregivers, is not typically covered under standard Medicare home health benefits. Medicare’s home health coverage is primarily focused on providing skilled nursing care, therapy services, and other medically necessary services to individuals who are homebound and under the care of a physician.

However, respite care may be available through other Medicare programs or supplemental coverage options. For example:

• Medicare Hospice Benefit: If a person is enrolled in Medicare’s hospice benefit, short-term respite care may be covered. Hospice care is provided to terminally ill patients who have a life expectancy of six months or less, and respite care is designed to give their caregivers a break. During respite care, the patient may temporarily stay in a Medicare-approved facility, such as a hospice inpatient facility, nursing home, or hospital, for up to five consecutive days, while the caregiver takes a break.
• Medicare Advantage Plans: Some Medicare Advantage plans may offer additional benefits beyond what Original Medicare covers, including respite care services. If you have a Medicare Advantage plan, you should review the plan’s benefits to see if respite care is included and what the coverage entails.
• Long-Term Care Insurance: Individuals who have long-term care insurance policies may have coverage for respite care services. Long-term care insurance policies vary in terms of coverage, so it’s essential to review the specific policy to understand what is covered.

If you or someone you care for needs respite care, it’s important to explore all available options for coverage and assistance. You can contact Medicare or your insurance provider for more information on coverage options for respite care. Additionally, local community resources and nonprofit organizations may offer support services for caregivers that include respite care assistance.