By Molly Thomas, FPQP®
The answer to this question is truly “it depends.” Medicare draws a line in the important distinction between medically necessary home health care and personal care services. Understanding the difference between these two levels of care is key to determining who is eligible for Medicare-covered in-home services.
If home health care services are to be covered by Medicare, the services must be ordered by your doctor, and one of the more than 11,000 Medicare Certified home health agencies must provide the care. Under these circumstances, Medicare can pay the full cost of home health care for up to 60 days at a time. Before you start receiving your home health care, the home health agency should tell you how much Medicare will pay. The agency should also tell you if any items (or services) they provide aren’t covered by Medicare, and how much you’ll have to pay. This information should be explained by both talking with you and in writing. The home health agency will give you a notice called the “Advance Beneficiary Notice” (ABN) before providing you services and supplies that Medicare doesn’t cover.
After the first 60 days, Medicare will continue to provide coverage if your doctor recertifies at least once every 60 days that the home services remain medically necessary. Your doctor (or other health care provider) may recommend you have the services more often than Medicare covers, or they may recommend other services not covered. If this happens, you may have to pay some (or all) of the costs.
To be eligible for Medicare home health benefits, all these conditions must be met:
• You are homebound: you are unable to leave home without considerable effort or without the aid of another person or a device such as a wheelchair or a walker.
• You have been certified by a doctor, or by a medical professional who works directly with a doctor (such as a nurse practitioner) as needing intermittent occupational therapy, physical therapy, skilled nursing care and/or speech-language therapy.
• Your certification arises from a documented, face-to-face encounter with the medical professional no more than 90 days before (or 30 days after) the start of home health care.
• You are under a plan of care that a doctor established and reviews regularly. The plan should include what services you need (and how often), who will provide them, what supplies are required, and what results the doctor expects.
• Medicare has approved the home health agency caring for you.
Either element of original Medicare Part A hospital insurance and/or Part B doctor visits and outpatient treatment might cover home care. Services include these:
• Skilled nursing care such as changing wound dressings, feeding through a tube, and injecting medicine, provided on a part-time or intermittent basis. Your combined home nursing and personal care cannot exceed eight hours a day or 28 hours a week, except in limited circumstances. (If you need full-time or long-term nursing care, you probably will not qualify for home health benefits.)
• Home health-aides to assist with personal activities such as bathing, dressing, or going to the bathroom if such help is necessary because of your illness or injury. Medicare covers these services only if you also are receiving skilled nursing or therapy.
• Occupational, physical, and speech therapy with professional therapists to restore or improve your ability to perform everyday tasks, speak or walk in the aftermath of an illness or injury or to help keep your condition from getting worse.
• Medical social services such as counseling for social or emotional concerns related to your illness or injury, if you’re receiving skilled care and help finding community resources if you need them.
• Medical supplies such as catheters and wound dressings related to your condition when your home health agency provides them. This might also include durable-medical equipment from the home health agency, such as walkers or wheelchairs, but for those Medicare does not pay the full cost. (You usually are responsible for 20 percent of the Medicare-approved amount.)
Medicare does not cover:
• Twenty-four-hour care at home
• Custodial or personal care when this is the only home care you need.
• Household services such as shopping, cleaning, and laundry when they are not related to your care plan.
• Meal delivery to your home
Again, “it depends”: the more you know about Medicare and what Medicare provides for home health care services can help you make the right decisions for yourself or a loved one and guide you accordingly for planning for those home health care needs.
Molly A. Thomas, FPQP® attended Erskine College and graduated from the College of Charleston with a B.S. in Education in 1981. She joined Abacus in February 2004. In April 2008, Molly received her certificate of completion from Florida State University in Insurance Planning and Risk Management, and she was awarded the Registered Para Planner Designation from The College of Financial Planning in 2012.
Abacus https://www.abacusplanninggroup.com/ is a financial advisory and investment counsel firm known for its passion in creating abundance for clients and family businesses through skillful listening and smart financial decision making. Managing over a $1.6 billion on behalf of its 250 plus families, Abacus consists of a team of multi-disciplinary experts who work collaboratively to serve its clients.