How does Medicare pay for home health?
What does Medicare cover?
Skilled nursing services are covered when they’re given on a part-time or intermittent basis. In order for skilled nursing care to be covered by the Medicare home health benefit, your care must be necessary and ordered by your doctor for your specific condition. You must not need full time nursing care and you must be homebound. See page 5.
Medicare uses the following criteria to assess whether these therapy services are reasonable and necessary in the home setting:
1. The therapy services must be a specific, safe, and effective treatment for your condition.
2. The therapy services must be complex or your condition must require services that can safely and effectively be performed only by qualified therapists. Section 1: Medicare Coverage of Home Health Care 9
3. One of the three following conditions must exist:
4. The amount, frequency, and duration of the services must be reasonable.
These services are covered when given under the direction of a doctor to help you with social and emotional concerns related to your illness. This might include counseling or help finding resources in your community.
Supplies, like wound dressings, are covered when they are ordered as part of your care. Durable medical equipment, when ordered by a doctor, is paid separately by Medicare. This equipment must meet certain criteria to be covered. Medicare usually pays 80% of the Medicare-approved amount for certain pieces of medical equipment, such as a wheelchair or walker. If your home health agency doesn’t supply durable medical equipment directly, the home health agency staff will usually arrange for a home equipment supplier to bring the items you need to your home.
Note: Before your home health care begins, the home health agency should tell you how much of your bill Medicare will pay. The agency should also tell you if any items or services they give you aren’t covered by Medicare, and how much you will have to pay for them. This should be explained by both talking with you and in writing.
The home health agency is responsible for meeting all your medical, nursing, rehabilitative, social, and discharge planning needs, as reflected in your home health plan of care. See page 19. This includes skilled therapy services for a condition that may not be the primary reason for getting home health services. Home health agencies are required to perform a comprehensive assessment of each of your care needs when you’re admitted to the home health agency, and communicate those needs to the doctor responsible for the plan of care. After that, home health agencies are required to routinely assess your needs.
What isn't covered by Medicare?
Homemaker services like shopping, cleaning, and laundry when this is the only care you need, and when these services aren’t related to your plan of care. See page 19
Talk to your doctor or the home health agency if you have questions about whether certain services are covered. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Note: If you have a Medigap (Medicare Supplement Insurance) policy or other health insurance coverage, be sure to tell your doctor or other health care provider so your bills get paid correctly.
What are the advantages of home health care?
In many cases, home health care permits a person to be discharged earlier from a hospital, reduces hospital admissions, assists with a more rapid recovery. Most importantly, people are happier at home and receive more care and attention from family, friends and home health care professionals.