David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories.
Medicare covers a variety of health care services that can be provided in the comfort and privacy of the individual’s home. These include intermittent skilled nursing care, physical therapy, speech-language pathology services, and occupational therapy.
Such services used to be available only at a hospital or doctor’s office. But they’re just as effective, more convenient, and usually less expensive when you get them in the home.
Those who get Medicare benefits through a Medicare Advantage health plan (instead of Original Medicare) should check with the plan for details about how it provides Medicare-covered home health benefits.
To be eligible for home health services, an individual must be under a doctor’s care and receive the services under a plan of care established and reviewed regularly by a physician. The doctor also needs to certify that you need one or more home health services.
In addition, the recipient must be homebound and have a doctor’s certification to that effect. (Being homebound means leaving the home isn’t recommended because of the patient’s condition, or the condition keeps the patient from leaving without using a wheelchair or walker, or getting help from another person.) Also, the patient must get their services from a home health agency that is Medicare-approved.
If the patient meets the criteria, Medicare pays for covered home health services for as long as they are eligible and their doctor certifies that the services are needed.
Skilled nursing services are covered when they’re given on a part-time or intermittent basis. In order for Medicare to cover such care, it must be necessary and ordered by the patient’s doctor for their specific condition. The patient must not need full-time nursing care.
Skilled nursing services are provided either by a registered nurse or a licensed practical nurse under an RN’s supervision. Nurses provide direct care and teach the patient and their caregivers about the care required. Examples of skilled nursing care include: giving IV drugs, shots, or tube feedings; changing dressings; and teaching about prescription drugs or diabetes care. Any service that could be done safely by a non-medical person (or by the individual patient) without the supervision of a nurse isn’t skilled nursing care.
Physical therapy, occupational therapy, and speech-language pathology services have to be specific, safe, and effective treatments for the patient’s condition.
Before home health care begins, the home health agency should tell the patients how much of their bill Medicare will pay. The agency should also advise the patient if any items or services they give aren’t covered by Medicare, and how much the individual will have to pay for them. This should be explained by both talking with patient and in writing. The agency should give the patient a notice called the Home Health Advance Beneficiary Notice (HHABN) before providing services and supplies that Medicare doesn’t cover.
Examples of what isn’t covered include:
• 24-hour-a-day care at home;
• Meals delivered to the patient’s home;
• Homemaker services like shopping, cleaning, and laundry (when this is the only care needed and when these services aren’t related to the patient’s plan of care);
• Personal care given by home health aides like bathing, dressing, and using the bathroom (when this is the only care needed).
If the patient’s doctor decides they need home health care, the patient can choose from among the Medicare-certified agencies in their area. (However, Medicare Advantage plans may require that the individual get home health services only from agencies with which they contract.)
One good way to look for a home health agency is by using Medicare’s “Home Health Compare” Web tool, at www.medicare.gov/ HHCompare. This tool allows the comparison home health agencies by the types of services they offer and the quality of care they provide.
For more details on Medicare’s home health benefit, please read the booklet, Medicare and Home Health Care. It can be found online at http://www.medicare.gov/ publications/pubs/pdf/10969.pdf.
About the author
David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).