Home Health Services and Medicare

What does Medicare Cover for Home Healthcare?

If you’re looking for an answer to the question, “What does Medicare cover for home healthcare?”, you’ve probably typed it into a search engine and immediately closed the tab. The amount of information and the level of detail can quickly become confusing and overwhelming. That’s why we’ve broken down this important query into a series of questions, looking at what home healthcare services are available, what services are covered, who is eligible and what costs you can expect to incur.

Experiencing a health emergency, like an injury from a fall or a heart attack, often requires hospitalization. While the hospital stay may be for only a short time, the individual may need support when they return home. Medicare can provide home healthcare services to help during that individual’s recovery.

So, under what circumstances will Medicare pay for home healthcare?

Firstly, What Exactly do We Mean by Home Healthcare?

This kind of care is planned to provide health services and equipment to individuals while they are in recovery at home. Home healthcare includes a wide variety of health and social services supplied in the home to treat illness or injury. 

Medicare covers such home health services under both Parts A and B when the services are medically “reasonable and necessary” and when:

  • A physician or other authorized healthcare provider has produced a plan of care for delivering the services that are reviewed as required.
  • The individual is confined to home, usually specified as “homebound.” This criterion is generally met if non-medical absences from home are infrequent and leaving home entails a considerable and difficult effort, which may be disclosed by the individual needing personal assistance or the help of an assistive device, e.g., a wheelchair or walker. (Attendance at an adult day care center, religious services or a special occasion is not a barrier to meeting the homebound condition.)
  • The individual needs skilled nursing care on an occasional basis or physical therapy or speech-language pathology, and
  • Such services are delivered by or under the agreement with a Medicare-certified home health agency.

What are the Range of Home Health Benefits?

Either component of original Medicare – Part A hospital insurance and/or Part B doctor visits and outpatient treatment – might cover home care. Services include:

  • Skilled nursing care, e.g., changing wound dressings, feeding through a tube or injecting machine, provided on a part-time or sporadic basis. The combination of the home nursing and personal care can’t go beyond eight hours a day or 28 hours a week, with the exception of certain circumstances. If there is need for full-time or long-term nursing, an individual most likely will not qualify for Medicare home health benefits.
  • Home health aides to help with personal behaviors such as bathing, dressing or going to the bathroom if such assistance is required because of the individual’s illness or injury. Medicare covers these services only if the individual is also obtaining skilled nursing or therapy.
  • Occupational, physical and speech therapy via professional therapists to reestablish or improve the individual’s ability to accomplish routine chores, speak or walk as a consequence of an illness or injury or to help keep the ailment from getting more serious.
  • Medical services such as counseling for social or emotional issues associated with the individual’s ailment or injury if they are getting skilled care and help locating community resources if required.
  • Medical supplies such as catheters and wound dressings associated with the individual’s disorder when their home health agency supplies them. This could also consist of durable medical equipment from the agency, such as walkers or wheelchairs; however, for these appliances, Medicare does not pay the full cost. The individual is normally liable for 20 percent of the Medicare-approved amount.

Medicare Does Not Pay for All Care at Home

As an example, it does not cover these services:

  • 24-hour care at home;
  • Custodial or personal care when this is the only home care the individual requires;
  • Household services including shopping, cleaning and laundry when they are not linked to the individual’s care plan;
  • Meal delivery to the home.

What Exactly is Meant by Skilled Therapy Services?

Skilled therapy services are those that must be delivered by or under the direction of a certified physical therapist, occupational therapist or speech-language therapist.

  1. Physical therapy exercises normally revolve around increasing and restoring strength, balance and range of motion for the best possible physical performance.
  2. Occupational therapy lends a hand in recovering the capacity to independently take part in the goings-on of everyday living and fine-tuning these tasks or the immediate surroundings to enhance the individual’s functionality and ease of access.
  3. Speech-language therapy assists patients in recovering the power to speak and communicate as well as surmount swallowing complications.

It’s imperative to be aware that the above services will only be covered if they are considered specific and effective treatment or maintenance methods for an individual’s condition. Additionally, Medicare standards will determine the eligible frequency and duration of any treatments. Once the level or care exceeds part-time or “intermittent” skilled care, Medicare is no longer a payment option.

In Medicare’s eyes, home healthcare services are intended to avoid or postpone placement in an assisted living or skilled nursing facility, not entirely replace them!

Does Medicare Cover Unskilled Home Care Services?

Medicare won’t pay for unskilled home care if those are the only services required. Personal home care services (help with activities of routine living) or homemaker services (e.g., light housekeeping and laundry) will only be covered if they are a segment of the skilled services specified in the individual’s care plan. 

How has COVID-19 Affected Home Healthcare Services?

During the COVID-19 pandemic, Medicare has sanctioned nurse practitioners, clinical nurse specialists and physician assistants to supply home health services without needing authorization from a doctor.

Key Takeaways:

  • If an individual is homebound with an injury or illness or have just been hospitalized, they may need home healthcare services.
  • Medicare supplies treatment for certain home healthcare services under Medicare Part A or Part B.
  • Medicare has detailed guidelines about home healthcare coverage. It’s essential for the individual to understand which plan will and will not repay.
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