|Medicare Does Not Cover Everything:Many, Americans benefit from care provided by home health agencies. Baby boomers and the loved ones they care for often need to make critical decisions about home health care with limited understanding of the care and what services Medicare covers. Home health care is provided when there is a medical need for skilled nursing care and other services, like physical and occupational therapy, speech-language therapy, and medical social services. Home health care is provided by a variety of skilled health care professionals at home and most home health care is temporary and part-time. Home health staff provides the care ordered by a doctor. They may also teach patients (and those who help them) how to continue the care needed, such as wound care and managing medication. Medicare will help cover home health care costs for beneficiaries who meet the following four conditions:
A doctor must decide that medical care is needed at home, and make a home care plan;
The patient must need at least one of the following: intermittent skilled nursing care, or physical therapy or speech-language therapy or continue to need occupational therapy;
The patient must be homebound. This means that they are normally unable to leave home unassisted. Being homebound means that leaving home is a major effort. When leaving home, it must be to get medical care, or for short, infrequent non-medical reasons such as a trip to get a haircut, or to attend religious services or adult day care.
The home health agency providing care must be approved by the Medicare program.
If all four of the conditions above are met, Medicare will help cover:
Skilled nursing care on a part-time or intermittent basis. Skilled nursing care includes services and care that can only be performed safely and correctly by a licensed nurse (either a registered nurse or licensed practical nurse)
Home health aide services on a part time or intermittent basis. A home health aide does not have a nursing license. The aide provides services that give additional support to the nurse. These services include help with personal care such as bathing, using the toilet or dressing. These types of services do not need the skills of a licensed nurse. Medicare does not cover home health aide services unless you are also getting skilled care such as nursing care or other therapy. The home health aide services must be part of the home care for your injury or illness.
Physical therapy, speech-language therapy and occupational therapy for as long as a doctor says it is needed.
Physical therapy, which includes exercise to regain movement and strength to a body area, and training on how to use special equipment or do daily activities, like how to get in and out of a wheelchair or bathtub
Speech-language therapy (pathology services), which includes exercise to regain and strengthen speech skills
Occupational therapy, which helps you to become able to do usual daily activities by yourself. Such as new ways to eat, put on clothes, and new ways to do other usual daily activities. Occupational therapy may continue to be received even if other skilled care is no longer needed.
Medical social services to help with social and emotional concerns related to an illness. This service is also only available when a skilled need exists. This might include counseling or help in finding resources in the community.
Certain medical supplies, like wound dressings, but not prescription drugs.
Certain medical equipment, such as a wheelchair or walker. Medicare usually pays 80% of the approved amount for some medical equipment.
Medicare does not pay for:
24-hour-a-day care at home.
Prescription drugs (with a few exceptions –ask your doctor).
Meals delivered to a patient’s home.
Homemaker services like cleaning, laundry and shopping.
Personal care given by home health aides, like bathing, using the toilet, or help in getting dressed when it is the only care needed.
The Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, offers free resources to help in the home health care decision-making process. For more information about Medicare home health care coverage, call 1-800-MEDICARE (1-800-633-4227), or visit http://www.medicare.gov/cost and click on “Publications” to read Medicare and Home Health Care.
CMS has also introduced a new resource called Home Health Compare on www.medicare.gov with information on Medicare-certified home health agencies. Administrative data and measures of quality are available to help users make more informed decisions about home health care. Quality of care is an important consideration, and the new publicly available measures can help make home health care decisions easier. For those without Internet access, Home Health Compare information is available by calling 1-800-MEDICARE. CMS also reports quality measures on nursing homes with Nursing Home Compare.
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