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Medicare Home Health Care Benefits

What Home Health Care Services Wont Medicare Cover

4 Seniors: Does Medicare cover home health care?

Additional services that you or a supplemental insurance will have to pay for include:

  • 24-hour at-home care
  • Custodial or personal care for help with daily living activities if thats the only care you need
  • Household services, such as shopping, cleaning and laundry when theyre not related to your care plan
  • Meal delivery to your home

Home Health Utilization And Expenditure Trends

Changes in the benefit, the provider industry, and the characteristics of home health care users have strongly affected home health care utilization and expenditure trends.

Since Medicare began in 1966, eligibility and coverage requirements for Medicare home health care have changed several times. In 1972, Medicare coverage was extended to persons under 65 years of age who are either disabled or have end stage renal disease. In that same year, the 20-percent copayment for home health care under Part B was eliminated. The Omnibus Reconciliation Act of 1980 eliminated home health care eligibility requirements of a 3-day prior hospital stay, Part A copayments, and a 100-visit limit. It also allowed for Medicare certification of for-profit HHAs. Most recently, Medicare Home Health Agency Manual revisions clarified coverage criteria in order to reduce inconsistencies in coverage determinations by intermediaries and to comply with the settlement of Duggan vs. Bowen . In this decision, a Federal district court found that Medicare’s interpretation of the phrase part-time or intermittent was too narrow, resulting in denial of care for eligible beneficiaries.

As a result of changes in the benefit, the industry, and beneficiary needs, Medicare home health care costs have grown substantially. Indeed, home health care is the most rapidly growing component of Medicare expenditures. Recent trends include the following:

How Does It Work

Supplementary health and dental insurance policies are contracts between you and an insurance company. You agree to pay a yearly or monthly fee called a premium, and the company agrees to pay the benefits which are covered under your policy. Your policy will outline what is included and what is not.

Here are some common features of supplementary health and dental insurance:

  • Most policies do not cover 100 per cent of your medical expenses. You may have to pay some of the medical expenses you and your dependants incur. This is known as the deductible. Each policy is structured differently and you might have family deductibles or per service deductibles .
  • Some plans have a co-insurance feature in addition to the deductible. That means you have to pay a percentage, or co-insure, the medical expenses on top of your deductible. It could be 10 per cent of the eligible medical expense, or higher, and it may depend on the type of medical service required.
  • You may also have dollar or percentage limits, or maximums placed on the amount of benefits that you can receive. Maximums can apply to specific health benefits like eyeglasses or massage therapy sessions in a specified period typically a year, or during your lifetime.

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Medicare Advantage Plans Can Cover Home Health Care Services

Medicare Advantage plans combine the benefits covered by Medicare Part A and Part B into one single plan sold by a private insurance company.

Many Medicare Advantage plans may also offer some additional benefits not covered by Original Medicare, such as dental care and prescription drug coverage.

Medicare Advantage plans cover the same home health care services that are covered by Medicare Part A and Part B.

Some Medicare Advantage plans may offer an expanded list of benefits that include:

  • Transportation to doctor’s appointments
  • Grab bars in home bathrooms
  • Healthier food options
  • Air conditioners for people with asthma
  • Home-delivered meals
  • Home health aides to help with daily activities like dressing or eating
  • Caregiver support services

Find Medicare Advantage plans that cover home health care

Or call 1-800-557-6059TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles hes written, helping Americans better understand their health insurance and Medicare coverage.

Christians work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Medicare has neither reviewed nor endorsed this information.

The Medicare Home Health Benefit: An Unkept Promise

How does Medicare home health care work and what type of Medicare home ...

An in-home nurse cares for the mother of the photographer while she continues to recover from COVID-19 at her home on May 6, 2020, in Baltimore. Medicare rules state that if a beneficiary is considered homebound and requires skilled nursing, physical therapy, or speech language pathology services, he or she also can qualify for dependent services, including home health aides. Photo: Arturo Holmes via Getty Images

An in-home nurse cares for the mother of the photographer while she continues to recover from COVID-19 at her home on May 6, 2020, in Baltimore. Medicare rules state that if a beneficiary is considered homebound and requires skilled nursing, physical therapy, or speech language pathology services, he or she also can qualify for dependent services, including home health aides. Photo: Arturo Holmes via Getty Images

  • Associate Director, Center for Medicare Advocacy

  • Associate Director, Center for Medicare Advocacy

  • Misunderstandings about Medicare-covered home health care, along with changes in Medicare payment and regulations, have greatly restricted access to these important services

  • Home health benefits could help many beneficiaries with long-term or debilitating conditions, but a lack of information and misaligned incentives prevents them from receiving this care

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Medicare Home Health Care Services

Sec 1861 of the Social Security Act, here are the following Medicare covered home health care services:

1. Skilled Nursing services at home on a part-time or intermittent basis

2. Home health aides on a part time or intermittent basis . Home health care is ONLY provided if a skilled service is certified to be needed FIRST â up to 28 hours per weekâ¦but for less than 8 hours per day. Exceptional circumstances can increase Medicare’s home care hours to 35 hours per week.

Medicare home care providers can provide hands-on personal care: bathing, dressing, grooming, caring for hair, nails, oral hygiene to facilitate treatment or prevent deterioration, changing bedlinen of incontinent patient, feeding assistance, routine catheter and colostomy care.

These items do not required skilled nursing care, but skilled care or skilled therapy is needed in order to qualify for these limited non-skilled services. This is the primary reason why Medicare’s home health benefits are more difficult to qualify for as compared to the Medicaid Waiver home care benefit .

3. Physical Therapy

6. Social Services

7. Routine and Non-Routine Medical Supplies .

8. Durable Medical Equipment needed for the treatment of illness, injury or condition at home or assisted living facility

9. Osteoporosis injectable drugs.

How Long Does Medicare Pay For Home Health Care

Medicare will pay for your in-home care for as long as your doctor deems the services necessary and you meet the eligibility criteria.

Home health services like skilled nursing and health aide services are only covered on a part-time or intermittent basis. This means Medicare will only pay for these services for up to a maximum of 8 hours per day and no more than 28 hours weekly.

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Getting Home Health Services In Certain States

If you live in Massachusetts, Michigan, Florida, Illinois, or Texas, you may be eligible for a Medicare demonstration program. Under this program, you can request a pre-claim review to let you know early on whether Medicare coverage will likely cover your home health services.

If youâre a resident of one of these states, you might want to request a pre-claim review as soon as your doctor orders your home health care. This way, youâll know as soon as possible whether youâll be on the hook for any payments.

Ready to get started? Find a plan that fits your budget and covers your doctor and prescription medications now.

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Home Health Services Covered By Original Medicare

Understanding Medicare Part A

If youre eligible for Medicare-covered home health care, services covered may include:4

  • Part-time or intermittent skilled nursing care
  • Physical therapy
  • Part-time or intermittent home health aide services
  • Injectable osteoporosis drugs for women

Note: Medicare will not pay for 24-hour-a-day care or meals delivered to your home. It also wont cover homemaker, custodial or personal care if thats the only care you need.5

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Administrative And Operational Improvements

Administrative and operational changes to improve program efficiency and integrity are also being addressed through the Home Health Initiative. HCFA needs to improve its ability to ensure that the program pays for only those services that are medically reasonable and necessary and meet home health coverage requirements. Data collection, audit processes , and coordination of services for beneficiaries dually entitled to Medicare and Medicaid have been identified as areas for initial attention.

For example, the forms used to determine eligibility, coverage, and patient care plans have been legitimately criticized for requiring documentation that is of little value to physicians and other professionals in care planning. Treatment codes may be inconsistently applied, in part, because home health care services are ill-defined. Further, the growing volume and intensity of home health care necessitates an evaluation of current medical review processes, including a reexamination of how cases are selected for review and a consideration of giving HHAs greater responsibility for utilization review.

Among the steps we are now taking in response to these problems are the following:

Home Health Patient Rights

As a person with Medicare, you have certain guaranteed rights and protections. By federal law, patients of a Medicare-approved home health agency also have these rights:

  • Choose your home health agency.
  • Have your property treated with respect.
  • Be given a copy of your plan of care, and participate in decisions about your care.
  • Have your family or guardian act for you if you are unable.

The home health agency must give you a written copy of your rights. For more information on your privacy rights as a home health patient, read the Home Health Agency OASIS Statement of Patients Privacy Rights.

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Does Medicare Cover Unskilled Home Care Services

Medicare will not pay for unskilled home care if those are the only services needed. Personal home care services or homemaker services will only be covered if they are part of the skilled services detailed in the care plan. Medicare does not cover around-the-clock home care of any kind or meals delivered to the home.

Which Home Health Services Does Medicare Cover

CMS Officially Adds Non
* Medicare coverage rules may change anytime. Please call us for the recent up to date coverages.

Medicare covers many different home health care services as long as you are eligible for coverage under Medicare Part A or Medicare Part B. In this guide, the team from At Home Personal Care clarifies the different services and eligibility requirements so that you can make informed choices on the type of care you receive, and that best fits your needs and circumstances. First, lets discuss what home health care is covered by Medicare Parts A and B:

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What Is Supplementary Health And Dental Insurance

If you live in Ontario, you are probably covered under the government-funded Ontario Health Insurance Plan . When you are approved for OHIP, youll get an Ontario health card which enables you to go to a doctor, clinic, hospital or emergency room, and receive medical attention, tests and surgeries at no cost to you.

But OHIP only partially covers or doesnt cover some medical services like prescription drugs and vision care, and it does not cover dental care. To pay for medical needs and dental care that OHIP doesnt cover, you may want to consider purchasing supplementary health insurance also known as extended health insurance, or private health insurance, and supplementary dental insurance.

You might have supplementary health and dental insurance through your employer, known as group insurance, or you may decide to buy your own policies, known as individual insurance. Supplementary health and dental insurance is a way to get the medical services you need, at an affordable price. To find out more about the different types of supplementary health and dental insurance, visit Types of Supplementary Health and Dental Insurance.

Services Medicare Doesnt Cover

Though Medicare can be a huge help in covering home health care, it doesnt cover everything. Here are some of the services that arent included as part of these benefits:

  • Around-the-clock care
  • Personal care services if you dont also require skilled medical care or therapy
  • Homemaking services if you dont also require skilled medical care or therapy.

Before your care starts, your Medicare-certified home health agency should present you with a breakdown of the charges and what Medicare will pay. This notice should also include how much youll be required to pay out of pocket.

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How Do I Qualify For Medicare Home Health Benefits

To be eligible for home health benefits, Medicare must approve the home health agency caring for you and you must meet the following criteria:

  • Be homebound. That means youre unable to leave home without considerable effort or the aid of another person or a device such as a walker or wheelchair.
  • Have certification from a physician or medical professional who works directly with a doctor, such as a nurse practitioner, showing you need intermittent occupational therapy, physical therapy, skilled nursing care and/or speech-language therapy. This certification entails a documented face-to-face encounter with a doctor or medical professional no more than 90 days before or 30 days after the start of your home health care.
  • Be under a plan of care that a doctor establishes and reviews regularly. That plan should note all services needed and how often, the provider, required supplies and the results your doctor anticipates. The doctor and home health team must review and recertify the care plan at least once every 60 days.

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Home health services are typically covered only if they are considered medically necessary by your doctor. A home health care agency can help you coordinate your home health services.

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Does Medicare Advantage Cover Home Health Care

Yes, Medicare Advantage plans cover home health care at the same level as Original Medicare. But Medicare Advantage plans may impose added rules, limitations and costs. Your plan may:

  • Restrict your care to plan-contracted providers
  • Require prior authorization or a referral from your family doctor on top of the mandatory Medicare certification
  • Charge deductibles, copays or coinsurance

Theres only one home-care related benefit that sets Medicare Advantage apart from Original Medicare: meal delivery. But not every Medicare Advantage plan offers it, and the benefits vary by plan: For example, one plan provides meals only for patients with a specific medical diagnosis. As a result, we dont recommend choosing Medicare Advantage based on this benefit alone.

In general, we found the Original Medicare home health benefit to be the better option for home care due to full coverage and fewer potential roadblocks to receiving care. Medicare Advantage plans may limit provider choice, assess fees or require referrals and preauthorizations for care. Medicare Advantage plans add very few extras for home health care or durable medical equipment when needed as part of home care.

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What Should I Expect From My Home Health Care

  • Doctors orders are needed to start care. Once your doctor refers you for home health services, the home health agency will schedule an appointment and come to your home to talk to you about your needs and ask you some questions about your health.
  • The home health agency staff will also talk to your doctor about your care and keep your doctor updated about your progress.
  • Its important that home health staff see you as often as the doctor ordered.

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Finding A Home Health Care Agency

If you are interested in home health care after a stay in the hospital, or as an alternative to a stay in a hospital or nursing facility, contact a home health care agency recommended by your doctor or the hospital discharge planner. The discharge planner can even contact an agency for you. You may also get help in locating home health care agencies from a community health organization, visiting nurses association, United Way, Red Cross, or neighborhood senior center. Medicare.gov lists home health care agencies in your area and allows you to compare the quality of their service depending on past performance.

How Do I Choose A Home Health Agency

Medicare Coverage of Home Health Care

To organize your search, build a home health agency checklist to help narrow your options. You may want to ask, for example, if the agency accepts Medicare payment or offers the specific services you need. You can use the checklist on the Medicare.gov website or create your own based on your personal health needs and budget.

Once you have your checklist ready, you can review home health agencies via the compare page on Medicare.gov. Click the home health services button to learn about providers near you, including quality ratings and contact information.

Recommended Reading: Chapter 7 Medicare Benefit Policy Manual

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