A Comprehensive Guide to Medicare Coverage for Home Health Care Services

There is a lot of confusion among home health service providers and patients regarding Medicare coverage for health care services provided at home. This lack of understanding affects the way these centers plan and submit reimbursement claims, often resulting in claim denials and rejections.

Medicare provides valuable coverage for a wide range of health services at home. Understanding Medicare’s coverage can help individuals make informed decisions about their health care options and access the necessary care from the comfort of their homes.

Let’s explore the details of Medicare coverage for home health care services, its eligibility criteria and the types of services covered.

Eligibility for Medicare Home Health Care Services

To be eligible for Medicare coverage of home health care treatment, you must meet the following conditions:

1. Under the Care of a Doctor: You must be under the care of a doctor or allowed practitioner, and your services must be part of a care plan created and regularly reviewed by a doctor or allowed practitioner.

2. Need for Skilled Services: You must require one or more of the following skilled services:
a. Intermittent skilled nursing care (other than drawing blood)
b. Speech-language pathology, physical therapy or continued occupational therapeutic services

3. Homebound Status: You must be homebound, which means:
a. You experience problems in leaving your home without assistance due to an injury, or medical condition
b. Leaving your home is not recommended because of your condition
c. You are normally unable to leave your home without significant effort

Medicare covered Home Health Care Services

Medicare Part A (Hospital Insurance) and/or Part B (Medical Insurance) cover eligible health care services, including:

1. Skilled Nursing Care: Medically necessary part-time or intermittent skilled nursing care provided by a qualified nurse.

2. Therapy Services:
a. Physical Therapy: Services provided by a physical therapist to help improve mobility, strength, and physical function.
b. Occupational Therapy: Services provided by an occupational therapist to assist with daily activities and improve independence.
c. Speech-Language Pathology: Services provided by a speech-language pathologist to address communication and swallowing disorders.

3. Medical Social Services: Counseling and support services provided by a medical social worker to help individuals and their families navigate health care resources and cope with social and emotional challenges.

4. Home Health Aide Care: Part-time or intermittent care provided by a health aide under the supervision of a skilled nurse. This is only covered if you are also receiving skilled nursing care at the same time.

5. Injectable Osteoporosis Drugs: Medicare covers injectable osteoporosis drugs for eligible women.

6. Durable Medical Equipment (DME): Certain medical equipment, such as wheelchairs or walkers, necessary for your care are covered under Medicare Part B.

7. Medical Supplies: Medicare coverage also includes supplies needed for your treatment, such as wound dressings or catheters.

Limitations of Medicare Coverage for Home Health care Treatment

It’s important to note that Medicare does not cover certain aspects of health care at home, including:

1. 24-Hour Care: Medicare does not cover round-the-clock care at home.
2. Homemaker Services: Services unrelated to your care plan, such as shopping or cleaning are not covered.
3. Custodial or Personal Care: Coverage doesn’t include assistance with activities of daily living, such as bathing, dressing, or using the bathroom.

Costs and Coverage Details for Home Health care Services

For insurance covered health care services at home, Medicare typically pays 100% of the costs, with no additional expenses for the beneficiaries. However, it’s important to be aware that 20% of the Medicare-approved amount may apply for medical equipment covered under Medicare Part B, after meeting the Part B deductible.

Before providing home health care services, the healthcare provider must submit a notice called the Advance Beneficiary Notice (ABN). This notice explains any items or services that Medicare does not cover and the associated costs. It’s essential to review this information and understand any potential expenses beforehand.