What home health services does Medicare cover?

An article by David Sayen, Medicare Regional Administrator:

Medicare covers a variety of heath care services that you can receive in the comfort and privacy of your home. These include intermittent skilled nursing care, physical therapy, speech-language pathology services, and occupational therapy.

Such services used to be available only at a hospital or doctor’s office. But they’re just as effective, more convenient, and usually less expensive when you get them in your home.

To be eligible for home health benefits, you must be under a doctor’s care and receive your services under a plan of care established and reviewed regularly by a physician. He or she also needs to certify that you need one or more home health services.

In addition, you must be homebound and have a doctor’s certification to that effect. (Being homebound means leaving your home isn’t recommended because of your condition, or your condition keeps you from leaving without using a wheelchair or walker, or getting help from another person.)

Also, you must get your services from a home health agency that’s Medicare-approved.

If you meet these criteria, Medicare pays 100 percent for covered home health services for as long as you’re eligible and your doctor certifies that you need them.

For durable medical equipment (like a walker, wheelchair, or oxygen equipment), you pay 20 percent of the Medicare-approved amount, after you pay the Part B deductible ($147 in 2013).

My comment: Medicare Advantage plans have the same rules as Medicare, charging the patient 20% of the rental or purchase cost for durable medical equipment (DME). Medicare Advantage plans generally do not have a deductible.

Skilled nursing services are covered when they’re given on a part-time or intermittent basis. In order for Medicare to cover such care, it must be necessary and ordered by your doctor for your specific condition. Medicare does not cover full-time nursing care.

Skilled nursing services are given by either a registered nurse or a licensed practical nurse under an RN’s supervision. Nurses provide direct care and teach you and your caregivers about your care. Examples of skilled nursing care include: giving IV drugs, shots, or tube feedings; changing dressings; and teaching about prescription drugs or diabetes care.

Any service that could be done safely by a non-medical person (or by yourself) without the supervision of a nurse, isn’t skilled nursing care.

Physical therapy, occupational therapy, and speech-language pathology services have to be specific, safe, and effective treatments for your condition.

Before your home health care begins, the home health agency should tell you how much of your bill Medicare will pay. The agency should also tell you if any items or services they give you aren’t covered by Medicare, and how much you’ll have to pay for them.

This should be explained by both talking with you and in writing. The agency should give you a notice called the Home Health Advance Beneficiary Notice before giving you services and supplies that Medicare doesn’t cover.

My comment:  Be sure to get in writing what you will pay for medical equipment (DME). I wrote about unexpected and costly surprise last year:  http://tucsoncitizen.com/medicare/2012/10/05/durable-medical-equipment-and-medicare-read-the-small-print/

What isn’t covered? Some examples:

• ·       24-hour-a-day care at home;
• ·       Meals delivered to your home;
• ·       Homemaker services like shopping, cleaning, and laundry (when this is the only care you need, and when these services aren’t related to your plan of care);
• ·       Personal care given by home health aides like bathing, dressing, and using the bathroom (when this is the only care you need).

If your doctor decides you need home health care, you can choose from among the Medicare-certified agencies in your area. (However, Medicare Advantage plans may require that you get home health services only from agencies they contract with.)

One good way to look for a home health agency is by using Medicare’s “Home Health Compare” web tool, at www.medicare.gov/HHCompare. This tool lets you compare home health agencies by the types of services they offer and the quality of care they provide.

For more details on Medicare’s home health benefit, please read our booklet, “Medicare and Home Health Care.” It’s online at http://www.medicare.gov/publications/pubs/pdf/10969.pdf.

David Sayen is Medicare’s regional administrator for Arizona, California, Nevada, Hawaii, and the Pacific Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).