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Medicare Coverage of Home Health Care

Who’s eligible?

If you have Medicare, you can use your home health benefits if you meet all the following conditions:
1. You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.
2. You must need, and a doctor must certify that you need, one or more of the following:
• Intermittent skilled nursing care
• Physical therapy
• Speech-language pathology services
• Continued occupational therapy
3. The home health agency caring for you must be approved by Medicare (Medicare-certified).
4. You must be homebound, and a doctor must certify that you’re homebound. To be homebound means the following:
• Leaving your home isn’t recommended because of your condition.
• Your condition keeps you from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person).
• Leaving home takes a considerable and taxing effort.

A person may leave home for medical treatment or short, infrequent absences for nonmedical reasons, such as attending religious services. You can still get home health care if you attend adult day care, but you would get the home care services in your home.

What Medicare covers If you’re eligible for Medicare-covered home health care, Medicare covers the following services if they’re reasonable and necessary for the treatment of your illness or injury:
• Skilled nursing care. 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.

Home health aide services may be covered when given on a part-time or intermittent basis if needed as support services for skilled nursing care. Home health aide services must be part of the care for your illness or injury. Medicare doesn’t cover home health aide services unless you’re also getting skilled care such as nursing care or other physical therapy, occupational therapy, or speech language pathology services from the home health agency.

• Physical therapy, occupational therapy, and speech-language pathology services. 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.
3. One of the three following conditions must exist:
• It’s expected that your condition will improve in a reasonable and generally-predictable period of time.
• Your condition requires a skilled therapist to safely and effectively establish a maintenance program.
• Your condition requires a skilled therapist to safely and effectively perform maintenance therapy.
4. The amount, frequency, and duration of the services must be reasonable.
• Medical social services. 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.
• Medical supplies. 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.

Note: 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. 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? Below are some examples of what Medicare doesn’t pay for:
• 24-hour-a-day care at home.
• Meals delivered to your home.
• 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
• Personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need.

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.

Contact

Phone: (210) 614-0200
or (210) 326-3630
Fax: (210) 569-6497

Physical address:
9502 Computer Drive,
Suite 102
San Antonio, Texas 78229

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