When Medicare pays for home health care

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Home care is a phrase commonly used to refer to a wide range of health and social services. These services are delivered at home to recovering, chronically or terminally ill persons or people with disabilities in need of medical, nursing, social or therapeutic treatment, and/or assistance with the essential activities of daily living.

Medicare will help pay for your home care if all four of the following are true:

1. You are considered homebound. Medicare considers you homebound if you meet the following criteria:  

  • You need the help of another person or special equipment (walker, wheelchair, crutches, etc.) to leave your home or your doctor believes that leaving your home would be harmful to your health; and
  • It is difficult for you to leave your home and you typically cannot do so.

2. You need skilled care. This includes skilled nursing care on an intermittent basis. Intermittent means you need care little as once every 60 days to as much as once a day for three weeks (this period can be longer if you need more care but your need for more care must be predictable and finite). This can also mean you need skilled therapy services. Skilled therapy services can be physical, speech or occupational therapy;*

3. Your doctor signs a home health certification stating that you qualify for Medicare home care because you are homebound and need intermittent skilled care. The certification must also say that a plan of care has been made for you, and that a doctor regularly reviews it. Usually, the certification and plan of care are combined in one form that is signed by your doctor and submitted to Medicare. 

  • As part of the certification, doctors must also confirm that they (or certain other providers, such as nurse practitioners) have had a face-to-face meeting with you related to the main reason you need home care within 90 days of starting to receive home health care or within 30 days after you have already started receiving home health care. Your doctor must specifically state that the face-to-face meeting confirmed that you are homebound and qualify for intermittent skilled care.
  • The face-to-face encounter can also be done through telehealth. In certain areas, Medicare will cover examinations done for you in specific places (doctors offices, hospitals, health clinics, skilled nursing facilities) through the use of telecommunications (such as video conferencing). 

4. You receive your care from a Medicare-certified home health agency (HHA).

*If you only need occupational therapy, you will not qualify for the Medicare home health benefit. However, if you qualify for Medicare coverage of home health care on another basis, you can also get occupational therapy. Even when your other needs for Medicare home health end, you should still be able to get occupational therapy under the Medicare home health benefit if you continue to need it.

If you have questions about billing issues for home health care you should contact 800-MEDICARE.


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What homebound means

 
LINKS
National Eldercare Locator

American Association of Colleges of Nursing (AACN)

Medicare.gov's Home Health Compare

The Federal Long-Term Care Insurance Program

National Clearinghouse for Long-Term Care Information

American Association of Homes and Services for the Aging (AAHSA)

National Long-Term Care Ombudsman Resource Center

National Directory of Long-Term Care Ombudsmen

 
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