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Medicare and Home Health Care

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Recently, a client inquired about “home health care” services for their disabled spouse who has been diagnosed with Alzheimer’s disease and now requires nearly 24-hour care.

When I had to explain to the client that Medicare does not provide that type of care, I thought it would be worthwhile to describe what home health care is and what it is not, as well as how a person qualifies to receive it.

What is Covered by Home Health Care?

Home health care is health and/or social services that a person receive in their home to treat an illness or injury.  Medicare home health care provides coverage for the following services:

  • Intermittent skilled nursing care
  • Physical, speech or occupational therapy
  • Care provided by a home health aide
  • Medical supplies for use in conjunction with home health care services

What is Not Covered by Home Health Care?

  • 24-hour home care
  • Homemaker services (cleaning, shopping, etc.) not related to a specific care plan
  • Meals delivered to a person’s home (though some Medicare Advantage plans provide for home delivered meals post-surgery)
  • Custodial care, which is care related to the activities of daily living (bathing, dressing, transferring, toileting, etc.) when this is the only care that is needed

Cost of Home Healthcare

The is no co-pay or coinsurance for covered home health care services.

If durable medical equipment is required in the course of a person receiving home health care, the Medicare Part B annual deductible will be assessed and a 20% coinsurance thereafter.

If a person is covered under a MediGap plan, then the plan might pay for some or all of the cost of durable medical equipment.

If a person is covered under a Medicare Advantage plan, then they will be assessed cost sharing based upon the benefits of their Medicare Advantage plan, up to the plan’s out-of-pocket-maximum.

How Does a Person Obtain Home Health Care?

Certain circumstances need to exist for Medicare to cover the costs of home health care.

First, a person my be considered “homebound,” meaning that they are essentially unable to leave their home.

Second, a person must require skilled nursing and/or skilled therapy on an intermittent basis, meaning they require care at least once every 60 days, but no more than once a day for up to three weeks.   The period of care can be longer if needed, but care needs to be considered both “predictable” and “finite.”

Medicare considers “skilled care” to be care that must be performed by a skilled professional or under the supervision of a skilled professional.

“Skilled therapy” refers to either physical therapy, speech therapy and/or occupational therapy.  A person cannot qualify for Medicare home health care if they only require occupational therapy, but they can have occupational therapy provided when they qualify for home health care on a separate basis.

Third, the person is required to have a face-to-face meeting with a physician within 90 days before starting home health care, or within 30 days of starting to receive home health care.  A face-to-face visit may be in the form of an office visit, a hospital visit or in some cases a telemedicine visit.

Forth, a person’s doctor must sign a home healthcare certification that indicates they are confined to their home and in need of intermittent skilled care, and this certification must be renewed every 60 days.  Within the certification, the doctor must include an approved plan of care and note that a face-to-face meeting took place.

Finally, it is important to note that a person must receive care from a Medicare-certified home health agency.

If you have any questions about home health care or any other Medicare questions, or if you just need help enrolling, please connect with one of our Member Agents.  There are never any fees for their educational or enrollment services!

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