Who can get Medicare-covered home health care and what services does Medicare cover?
If you have Medicare, home health care services are covered if you meet all the following conditions:
- Your doctor must decide that you need medical care at home, and make a plan for you care at home.
- You must need intermittent skilled nursing care, physical therapy, speech-language therapy or to continue occupational therapy.
- The home health agency caring for you must be approved by the Medicare program (5Medicare-certified)
- You must be homebound, or normally unable to leave home without help.
- To be homebound means that leaving home takes considerable and taxing effort.
- You can be homebound and still leave home for medical treatment or short, infrequent absences for non-medical reasons, such as trips to a barber or church.
- A need for adult day care doesn’t keep you from getting home health care.
If you meet all four of the conditions above, Medicare will cover the following types of home health care:
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 (5either a registered nurse or a licensed practical nurse).
Home health aide services on a part-time or intermittent basis. A home health aide doesn’t have a nursing license, but supports the nurse by providing services such as help with bathing, using the bathroom, dressing or other personal care. These types of services don’t need the skill of a licensed nurse. Medicare doesn’t 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 you illness or injury.
Physical therapy, speech-language therapy, and occupational therapy for as long as your doctor says you need it. 1. Physical therapy includes exercise to regain movement and strength in 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. 2. Speech-language therapy (5pathology services) includes exercise to regain and strengthen speech skills. 3. Occupational therapy includes exercise to help you do usual daily activities by yourself. You might learn new ways to eat, put on clothes, comb your hair, and perform other usual daily activities. You may continue to receive occupational therapy if ordered by your doctor even if you no longer need other skilled care.
Medical social services to help you with social and emotional concerns related to your illness. This might include:
- Counseling or help in finding resources in your community.
- Certain medical supplies, like wound dressings (5but not prescription drugs or biologicals).
- Durable medical equipment, such as a wheelchair or walker. It also includes oxygen equipment, hospital beds and other items that are “durable”. That is, you don’t use them once and throw them out.
Currently, Medicare does not cover (5does not pay for) any of the following:
- 24-hour-a-day care at home;
- Meals delivered to your home;
- Homemaker services like shopping, cleaning, and laundry; and
- Personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need.
Most of the time, your doctor, a social worker, or a hospital discharge planner will help arrange for Medicare-covered home healthcare. However, you have a say in which home health care agency you use.
You will pay $0 for all covered home health visits. It should also be noted that if you only have Medicare Part B, then these services will be covered under Part B. It is important to also understand that Medigap policies (5Medicare Supplement Insurance) no longer cover “At-home Recovery” or “Preventive Care Not Covered by Medicare.” However, Part A Hospice Care is included in all Medicare Supplement Insurance plans.
Durable medical equipment refers to items like oxygen equipment, wheelchairs, walkers, hospital beds, and other items that are “durable.” You don’t use them once and throw them out. You also use most of these items as part of in-home care. Durable medical equipment must also be ordered by a medical professional enrolled in Medicare. In some cases, equipment must be rented. You have to pay for 20 percent of Medicare-approved amount (5Part B deductible also applies here). Medicare is also beginning a new competitive bidding program that will save money and limit fraud. In some states you will need to get certain equipment from specific suppliers or Medicare will not pay, leaving you with the full bill. This program began January 1, 2011, in several metropolitan areas in California, Florida, Indiana, Kansas, Kentucky, Missouri, North Carolina, Ohio, Pennsylvania, South Carolina and Texas. It is scheduled to include areas in all 50 states by 2016.
Other items are considered durable medical equipment. These include: air fluidized beds, blood glucose monitors, bone growth stimulators, canes, commode chairs, crutches, infusion pumps (5and even some medicines used in such pumps), Lymphedema pumps/pneumatic compression devices, scooters, nebulizers (5and some medicines used), patient lifts, suction pumps, traction equipment, transcutaneous electronic nerve stimulators, and ventilators. This list is not comprehensive. A number of prosthetic and orthotic items are also considered “durable” and are covered.
You should note that Medicare will not cover motorized scooters and wheelchairs which are primarily used outside the home. Your doctor needs to verify that you need such a scooter for a medical condition. You must have a “certificate of medical necessity” to get any of these items or other durable medical equipment. Medicare usually pays 80% of costs of such equipment. Note that this is figured on the Medicare-approved amount for these items so the payment might actually be less than 80%. Different durable goods are covered in different ways as well. Some, for instance, may be rented.
Depending on your Medigap plan you should be able to get help paying for your share of these items. In some cases, the Medigap plan will fully cover your portion of the bill for durable medical equipment. Contact your insurance company and ask them specifically what is covered. When it comes to durable medical equipment, be sure to find out if your Medigap plan pays for 20% of the Medicare-approved amount, or if it covers any amount over what is covered by Medicare.
Medicare has neither reviewed nor endorsed this information.