How Does Medicare Coverage of Home Health Care Work?
Deciding on requesting home health care services for a loved one can be a complex decision, and figuring out how to pay for such services can add a layer of concern and multiple questions. Thankfully, Medicare can help cover these services if your loved one meets all the criteria—Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) cover eligible home health services as long as your loved one needs part-time or intermittent skilled services and is homebound.
While Medicare coverage of home health services is available, understanding what it covers, how long it pays, and what services are included can significantly improve access to care for loved ones. Keep reading for insights about Medicare benefits for home health care, including eligibility, services provided, and other essential factors to help you make an informed decision.
What Home Health Care Services Are Covered by Medicare?
Medicare covers a broad range of home health care services, provided the patient meets eligibility requirements. Here’s an overview of the services covered:
- Skilled Nursing Care: Medicare pays for care services performed by a licensed nurse, such as monitoring vital signs, administering medications and injections, managing wound care, and educating patients and caregivers about medical treatment.
- Therapy Services: Playing a crucial role in recovery and rehabilitation, therapy services can be provided at home. The following services are covered under Medicare:
- Physical therapy to help improve mobility, strength, and coordination
- Occupational therapy to aid patients in performing activities of daily living, such as dressing, eating, or using adaptive tools
- Speech therapy and speech-language pathology services to address communication and swallowing disorders
- Home Health Aide Services: Medicare covers intermittent home health aide services, which are only covered if the patient also receives skilled nursing care or therapy. These services assist with personal care tasks such as bathing, grooming, and dressing.
- Medical Social Services: By talking to medical social workers, patients and families navigate emotional, social, and financial challenges related to care. Social workers can also assist in finding additional resources and support systems.
- Durable Medical Equipment (DME): For durable medical equipment necessary for the patient’s care, such as wheelchairs, walkers, and hospital beds, Medicare covers 80% of the cost. Medicare pays for different kinds of DME in different ways. Depending on the type of equipment, you may need to rent the equipment or buy the equipment.
- Medical Supplies: Medicare covers certain medical supplies, such as wound dressings and catheters, used during home health visits.
How Long Will Medicare Cover Home Health Care Costs?
Medicare pays for covered home health services during an initial certification period of 60 days split into two 30-day episodes. On average patients are admitted to an agency for about 48 days per certification period. Payment for each 30-day period is based on your condition and care needs, which include the following:
- Skilled Nursing Care: Medicare covers intermittent skilled nursing care that is provided less than seven days a week, up to eight hours per day, or up to 28 hours per week. However, extensions are possible if deemed medically necessary by a doctor.
- Therapy Services: Coverage continues as long as the patient demonstrates progress or requires skilled therapy, such as physical therapy, occupational therapy, or speech therapy. A doctor’s certification is required to confirm the need for ongoing services.
- Eligibility Reviews: Medicare periodically reviews the patient’s condition to determine if home health services are still necessary. Once patient has achieved care goals established by the agency, the patient is discharged into the community, hospice or a non-skilled agency. Patients who no longer meet the criteria for Skilled services are no longer eligible to receive care from a Home Health Agency regardless of private insurance or Medicaid.
What’s not Covered under Medicare?
While Medicare provides extensive coverage for home health care, some services are excluded, such as custodial care that includes meal preparation, homemaker services, or grocery shopping. There is an exception if the services are being provided as part of skilled care.
Other services not covered include 24-hour home care and personal activities that include paying bills or running errands. If these services are required, families may need to explore alternate funding sources, such as Medicaid services, veterans benefits, or out-of-pocket payments.
Qualifying for Medicare Home Health Coverage
To qualify for home health care coverage under Medicare, patients must meet the following criteria:
- Face to Face Certification by a Qualified Clinician who certifies that the patient requires one or more of the following:
- Intermittent skilled nursing care
- Therapy services, such as physical therapy, speech therapy, or occupational therapy
- Medical social services
- Have Homebound Status: The individual must be considered homebound, meaning they have difficulty leaving their own home without assistance, or it is not medically safe.
- Have an Established Care Plan: The care must follow a specific plan detailing the services provided and their frequency. This plan needs to be established and reviewed by a doctor.
- Have a Medicare-Approved Agency as a Service Provider: Services must be provided by a Medicare-certified home health agency.
Financial Considerations for Home Health Care
Medicare typically covers 100% of the approved home health care services costs, except for durable medical equipment—patients are responsible for 20% of the cost. However, families should be aware of potential additional costs:
- Advance Beneficiary Notice (ABN): Patients may receive an ABN if Medicare denies coverage for a service. When you get an ABN, the notice should describe the service and/ or supply and explain why Medicare probably won’t pay. The ABN gives clear directions for getting an official decision from Medicare about payment for home health services and supplies and for filing an appeal if Medicare won’t pay.
- Private Insurance: If services exceed Medicare’s limits, private insurance may provide supplemental coverage.
- Medicaid Services: Low-income individuals may qualify for additional financial assistance through Medicaid.
If families find Medicare coverage insufficient, they can explore other options to ensure their loved one receives the necessary care. Veterans Benefits supports eligible veterans with additional home health care support through the VA. Additionally, if families can afford to do so, they can hire private caregivers for non-medical services, such as homemaker services and meal preparation. Lastly, assisted living or other senior living facilities may offer comprehensive care for patients who require ongoing support.
A Delicate Balance: Quality Care and Costs
Ensuring your loved one receives high-quality care often requires a major effort to balance their medical needs with financial resources. Take the following steps to optimize their care:
- Work with a Medicare-certified home health agency to ensure compliance with federal and state regulations and access to covered services.
- Consult a medical social services professional who can help you identify additional funding sources, community programs, and financial aid opportunities.
- Communicate with doctors or nurse practitioners to discuss the condition and care plan.
Care Support You Can Trust
Medicare offers significant support for families seeking home health care services, and understanding what it exactly covers, including how long it pays and what services are included, can make a difference in your and your loved one’s care decisions. To ensure your loved one receives the right care while managing costs effectively, working with a home health agency and exploring supplemental options is an essential step in your care.
Selecting the right home health agency is crucial for ensuring quality care. Boost Home Healthcare delivers the care you or your loved one needs in the space you love. Compared to hospitals or skilled nursing facilities, we offer more convenient and often more affordable care. As an added benefit, our approach is entirely personalized.
To learn how home health services can support your or your loved one’s care needs, start your assessment today by connecting to a Boost Home Healthcare location near you.
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