One of the most common questions we get is whether Medicare covers home healthcare services and, if so, which services does it cover. The good news is that Medicare does provide coverage for a variety of home healthcare services for beneficiaries who meet certain requirements. In this post, we describe the eligibility requirements and which services Medicare covers.
It’s important to note that all of what follows is true for Original Medicare beneficiaries. If you receive your benefits through a Medicare health plan, such as Medicare Advantage (MA), you should talk to your provider to determine whether your plan offers additional benefits.
Who Is Eligible for Home Healthcare?
Before describing which services Medicare covers, you need to know whether you qualify for home healthcare benefits. Please note that each of the following five items must apply to you in order to qualify.
First, you must be under a doctor’s care AND your doctor must have established a care plan that he or she reviews regularly.
Second, your doctor must certify that you require at least one of the following:
- Intermittent skilled nursing care beyond blood draws
- Occupational therapy
- Physical therapy
- Speech-language pathology services
We cover these qualifications in more depth in the What Services Does Medicare Cover? section.
Third, you must use a Medicare-certified home health agency to deliver your care. Fourth, your doctor must certify that you are homebound. This means that you may only leave your home for medical treatments and infrequent, non-medical events. However, if you regularly attend religious services or adult day care, you still qualify as homebound so long as your doctor certifies it.
Finally, your certificate of eligibility requires documentation from a doctor or other qualifying provider that he or she met with you face to face, for reasons related to your home healthcare needs, within a specified period.
What is intermittent skilled nursing care?
This is one of the areas where determining Medicare coverage gets confusing. First, we need to clarify that if skilled nursing care is your only home healthcare need, you do not qualify for these services. As stated above, you must meet each of the five eligibility requirements.
Next, we need to define intermittent. As per Medicare, this is care that you either need or receive fewer than 7 days per week OR you receive daily care for fewer than 8 hours per day with your doctor predicting your need for skilled nursing will end within 21 days. If your doctor expects you to need this level of care for an extended time, you do not qualify for home healthcare services.
What Services Does Medicare Cover?
If you are deemed eligible for home healthcare, Medicare covers five services, assuming they are considered necessary and reasonable to treat your condition.
Skilled nursing care
Medicare covers part-time or intermittent care that requires the specialized training of a nurse, so long as the nurse’s care is required for more than blood draws. Care must not exceed 8 hours per day or 28 hours in a week. In limited cases, Medicare will pay for up to 35 hours per week.
Your care must be provided by either a registered nurse (RN) or a licensed practical nurse (LPN) who is supervised by an RN. To qualify, the care required must not be of the type that a non-medical person could safely and effectively provide it. Examples include administering IV drugs, changing dressings, and providing instruction on diabetes care.
Physical therapy, occupational therapy, and speech-language pathology
You may receive these services in a home setting if they’re specific to treating your condition. They must also be complex enough that a qualified therapist must either perform or supervise the treatment. Your qualified therapist must establish a therapy program that is necessary to improve function that was impacted by your illness or injury. Finally, the “amount, frequency, and duration” of the services must be considered reasonable by Medicare.
Home health aide services
Medicare covers intermittent home health aide services if you are also receiving skilled care. This includes the above conditions for skilled nursing care and physical/occupational therapy or speech-language pathology.
Medical social services
If your doctor orders social services due to social or emotional concerns regarding your treatment, Medicare will pay for them provided you are receiving skilled care as described in the above sections.
This includes supplies that your doctor orders for your care, such as dressings.
Please note that durable medical equipment is a separate service that is not included as part of your home healthcare coverage. If the item is approved, it falls under the realm of your Medicare Part B benefits.
What Services Are Not Covered by Medicare?
This could potentially be a very long list, so we won’t list all of the items that Medicare does not cover. However, we want to point out that Medicare does not cover some services that people commonly associate with home healthcare. These include:
- 24-hour in-home care
- Homemaker services, such as cleaning and laundry
- Meal delivery
- Personal aid services, such as shopping
- Personal care services, such as bathing and using the bathroom (if this is the only care you require)
Before it begins to provide your home healthcare, the home health agency you choose should explain what is covered by Medicare and what expenses, if any, are your responsibility. This information should be given to you in writing.
If you have a Medigap plan, talk to your provider and home health agency to ensure proper billing. And, as always, if you have any questions about your Medicare plan, call us toll-free at 855-350-8101 (TTY 711) to speak to a licensed agent.
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