This article explains the what’s and how’s of Medicare’s home health care benefit. Home health care services are covered under Original Medicare (Parts A and B). If you are enrolled in a Medicare Advantage plan, your costs, coverage, and restrictions may be different. Contact your plan for further information on Medicare-covered home health benefits.
•How can I qualify for Medicare’s home health benefit? Before Medicare covers your home health care treatment you must be deemed eligible. Do you meet these criteria?
You are under the care of a doctor who must certify that you require skilled therapy and nursing care on an intermittent basis. “Intermittent” means less than 7 days per week for less than 8 hours each day and 28 hours per week for up to 21 days.
If you need full-time skilled nursing care, you won’t qualify for the home health care benefit.
You must receive your home health care from a Medicare-certified home health care agency.
You are homebound or unable to leave your home without major effort.
You and your doctor must have face-to-face encounters at certain intervals to determine your progress.
•What services will Medicare cover? A registered nurse or licensed practical nurse may provide skilled nursing services like giving IV drugs, injections, feeding tube maintenance, dressings and wound care.
Medicare pays for somebody to administer personal care if you are receiving one of the services above.
Home health aide services may include bathing, dressing, feeding, toileting, and transferring. You may receive treatment for social and emotional concerns if your doctor believes addressing those will help you recover quicker or may interfere with your treatment.
Medicare will cover wound dressings or other similar supplies as ordered by your doctor. You may also receive skilled physical, occupational or speech therapy as determined by your plan of care.
•What services are excluded from home health coverage? Medicare’s home health benefit does not cover 24/7- day care in the home, prescription drugs; home delivered meals; or custodial care (homemaker services).
•How much will I pay? Medicare covers the full cost. Patients have no deductibles or copays. Exception: Medicare pays 80 percent of the approved amount for durable medical equipment, such as for a wheelchair or walker. You pay 20 percent coinsurance.
•How long can I receive home health care? Unlike hospital and skilled nursing facility care, there is no legal limit to the duration of your home health coverage as long as you continue to meet the qualifying criteria. Medicare coverage is available for necessary home health care even if it extends over a long period of time.
In a legal case settled in 2013, there is no improvement standard for the continuation of care. Medicare-covered home care is justified to maintain or prevent decline of your health condition.
•What to do if my coverage is ending or denied? Denials for home health care benefits happen all too frequently. Medicare may deny a claim if they determine that you do not meet the definition of “homebound.” Home health care claims often get erroneously denied when a patient’s condition does not improve.
The courts have determined that improvement or progress is not necessary when skilled care is required. It is enough to show that skilled therapy and nursing are necessary to maintain an individual’s condition or to slow deterioration.
If a home health agency issues a notice that states your services will be ending, you have a right to an expedited appeal.
Ask your doctor to certify that failure to continue the provision of such services is likely to place your health at significant risk.
Your home health care should not end or be reduced unless your doctor specifically orders the change.
The home health agency must give you at least two days advanced notice before terminating your services.
A request for an expedited review, orally or in writing, must be made by noon of the next calendar day to preserve expedited appeal rights.
In order to appeal a Medicare denial, the home health agency must file a Medicare claim for your care, even if the agency thinks Medicare coverage is not available.
Just keep in mind that you may need to pay for your care pending Medicare’s decision or if Medicare is denied.
A successful appeal entails working with your doctor who ordered your care.
How can I find a Medicare-certified home health agency? Call Medicare’s customer service line at 1-800-633-4227 or go to Medicare’s website at www.medicare.gov for a list of Medicare-certified home health agencies in your area.
If you’re in a Medicare Advantage plan, call the plan directly to find out what agencies participate with your plan.
How can I receive further information about Medicare’s home health care benefit?
For more information about Medicare’s Home Health Care benefit, read the official Medicare publication, “Medicare and Home Health Care” at: https://www.medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf.
You can also contact your local APPRISE program. All counseling services are free and confidential. The toll-free APPRISE Helpline is (800) 783-7067.
Joel Mekler is a certified senior adviser. Send him your Medicare questions at firstname.lastname@example.org.