If you require in-home personal care or skilled nursing services due to recent hospitalization, chronic illness, or another circumstance that has confined you to your home, you may be eligible for home health care through Medicare.

We’ve thoroughly examined eligibility criteria, associated costs, and other pertinent details to provide a guide to Medicare’s home health benefits. Continue reading for an in-depth understanding of the program.

What is home health care?

Home health care involves part-time or intermittent clinical care delivered in your own home by healthcare professionals. It aims to help individuals who, due to illness or injury, find themselves confined to their homes, regain maximum independence.

People often confuse home health care, provided by skilled professionals, with home care, which is non-skilled or non-clinical care focused on supporting activities of daily living (ADLs). In general, home care is not typically covered by Medicare.

If you’re seeking coverage for home care, long-term care insurance might be an option. These plans cover extended care in various settings and can be relatively affordable if you apply in your early 50s or in good health. Medicaid might also include coverage for these services, given that you fulfill the income criteria specified by the program in your state.

Who qualifies for home health care services?

You may qualify for home health care services if you are homebound and require skilled care in your home on a part-time or intermittent basis due to a medical condition, accident, illness, or surgery.

Medicare defines being homebound as having difficulty leaving home without assistance from another person, special transportation, or a mobility aid. Furthermore, a healthcare professional such as a doctor, physician, nurse practitioner, or other qualified practitioner must confirm that you are homebound and require home healthcare services.

Individuals receiving home health care services may be living with a chronic condition such as diabetes or Alzheimer’s Disease, or they might be facing a temporary circumstance such as a recent surgery-related hospitalization or a medical emergency.

It’s worth noting that you can still qualify for home health care even if you attend adult daycare. Moreover, while receiving home health care, you are allowed to leave your home for occasional medical treatments or religious services.

Does Medicare cover home health care?

Medicare covers home health care under Original Medicare, which includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). You can receive home health care up to seven days a week but limited to a maximum of eight hours per day or 28 hours per week (with allowances for special cases where approval for up to 35 hours per week is possible).

To get home health care through Medicare, a doctor, nurse practitioner, or other healthcare professional must certify your need for the service. Additionally, the provision of home health care services must be carried out by a home health agency approved by Medicare.

If you are enrolled in a Medicare Advantage Plan (Part C), you can access the home health care benefit. However, eligibility requirements and restrictions may differ from those stipulated by Medicare for Part A and Part B. Seek guidance from your health insurance provider to ascertain the qualification process and potential out-of-pocket expenses. Additionally, the company can furnish you with a roster of endorsed home health agencies.

What home health services are covered by Medicare?

Medicare covers a range of home health services, from post-surgery care to assistance in relearning skills lost due to a medical condition or accident. Illustrations of services that are covered encompass:

• Skilled nursing services
  • Administering injections and providing instruction on self-injection techniques
  • Nutritional guidance
  • Tube feedings
  • Monitoring of blood pressure, temperature, breathing, and heart rate
  • IV therapy
  • Continued observation and assessment of condition
  • Catheter changes
  • Patient and caregiver education
  • Wound care
  • Pressure sore care
  • Medication management
• Skilled therapy services
• Home health aide services
• Medical social services
• Durable Medical Equipment (DME)* and medical supplies
  • Physical therapy
  • Speech-language pathology services
  • Occupational therapy (focuses on regaining the ability to perform daily activities, like eating and getting dressed)
  • Bathing
  • Going to the bathroom
  • Dressing
  • Counseling for emotional concerns
  • Help to find local resources
  • Wound dressings
  • Catheters
  • Wheelchair
  • Walker
  • Hospital bed

*Medicare covers 80% of the Medicare-approved amount for certain pieces of durable medical equipment (DME) prescribed by your doctor or healthcare provider. This means you will pay 20% coinsurance to rent or buy DME after meeting the Part B deductible.

What home health services are not covered by Medicare?

Some home health services are not covered by Medicare, including:

• 24-hour care in your home
• Meal delivery
• Homemaker services, including cleaning and shopping (unless related to your care plan)
• Custodial or parental care (if it’s the only care you need)
  
  

Note that you may not be eligible for home health care if you only need occupational therapy. You must receive home health care to be provided with occupational therapy. Additionally, if your doctor believes you require a higher level of care, if you opt for inpatient treatment at a skilled nursing facility, you may not qualify for home health care services.

It’s advisable to verify costs with the home health care agency before each period begins. If the agency doesn’t cover certain costs, they should provide you with this information in writing through an Advance Beneficiary Notice (ABN). You are expected to receive this notification before the agency offers any services or supplies that Medicare does not cover.

Additionally, if you live in Florida, Illinois, Massachusetts, Michigan, or Texas, you may be able to submit a request for a pre-claim review of coverage through the Medicare demonstration program.

How long will Medicare pay for home health care?

Medicare covers home health care for three weeks at a time, as long as you meet the eligibility criteria. Your home health agency should provide written notice via a Notice of Medicare Non-Coverage (NOMNC) at least two days before your home health benefit ends.

To continue care, a doctor or healthcare professional must once again submit certification of your need for home health care. Your doctor may adjust your plan of care during renewal.

In summary, if you need in-home care due to factors like recent hospitalization or chronic illness, Medicare may cover home health care. It’s essential to understand that home health care is provided in three-week intervals, subject to eligibility, and recertification is required for continued coverage. Maintain open communication with your healthcare team and confirm expenses with the agency to stay well-informed about the services covered.