How to Qualify for Home Health Care Under Medicare

Navigating the world of healthcare can be overwhelming, especially when you or a loved one needs specialized care. If you're considering home health care and wondering if Medicare will cover it, you're in the right place. Let's break down the criteria for qualifying for home health care under Medicare in a way that's both informative and easy to understand.

1. Be a Medicare Beneficiary

First things first, you need to be enrolled in Medicare. Specifically, you need to have Original Medicare (which consists of Parts A and B) or Medicare Advantage (Part C). Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care services. Part B covers medically necessary services, such as doctor visits, outpatient care, and some home health care services.

Tip: To find out if you're enrolled in both parts of Original Medicare, you can check your Medicare card or log into your account on the Medicare website.

Medicare Advantage (Part C), provides an alternative to traditional Medicare. This type of plan is provided by private companies, must provide at least the same coverage as Original Medicare, and often includes additional benefits. Each Medicare Advantage plan will have unique rules and requirements for home health care, so be sure to check your plan materials carefully. Your Medicare Advantage plan may require you to get home health services from agencies they contract with. Call your plan provider for more information.

 

2. Be Homebound

Being homebound is a key criterion for Medicare home health care. But what does "homebound" really mean? It doesn't mean you're bedridden or can't leave your home at all. Instead, it means that leaving your home is difficult and requires considerable and taxing effort. For example, if you have a severe heart condition or are recovering from major surgery, you might be considered homebound.

Example: Imagine you've recently had a hip replacement. You can still go outside for a short walk with a lot of effort, but it's not something you can do frequently or without significant assistance. In this case, you might be considered homebound. It’s important to note that lack of access to a car or driver’s license does not qualify someone as homebound.

3. Need Skilled Care

Medicare home health care is designed to provide skilled care, which means the services you need can only be provided by a licensed healthcare professional. This includes:

• Skilled Nursing Care: Think of tasks like wound care, injections, and managing medications. These are things that require a registered nurse (RN) or licensed practical nurse (LPN) under the supervision of an RN.
• Physical Therapy: If you need help with mobility, reducing pain, or improving physical function, physical therapy can be a game-changer.
• Speech-Language Pathology: If you have trouble speaking or swallowing, a speech-language pathologist can help.
• Occupational Therapy (if it’s not the only skilled service required): This helps you perform daily activities and improve your quality of life. For example, if you're having trouble dressing or cooking, an occupational therapist can provide strategies and adaptive equipment to make these tasks easier.

Note: If you only need help with basic tasks like housekeeping or companionship, Medicare won't cover these services. They are considered custodial care and are not medically necessary.

4. Get Certified by Your Home Health Care Provider

To get Medicare to cover your home health care, your healthcare provider needs to certify that you need these services and that they are medically necessary. This involves a few steps:

• Face-to-Face Evaluation: Your doctor must conduct a face-to-face evaluation to determine your need for home health care. This evaluation should document your condition and the specific services you require.
• Certification: Once your doctor has evaluated you, they must certify that you need home health care and that the services are medically necessary. This certification must be renewed periodically to ensure that your condition still requires home health care.

Tip: Keep a record of all your doctor's visits and any documentation related to your condition. This can be helpful if you need to appeal a decision later.

5. Create a Plan of Care

Once your healthcare provider has certified your need for home health care, they will create a plan of care. This plan should be detailed and include:

• Types of Services: What specific services you need, such as skilled nursing care, physical therapy, or speech-language pathology.
• Frequency of Visits: How often you will receive each service?
• Medical Equipment: What supplies, or equipment are needed?
• Goals of Care: What the expected outcomes are for your care.

Example: Your plan of care might include weekly visits from a physical therapist to help you regain strength and mobility after a hip replacement, along with bi-weekly visits from a skilled nurse to manage your medications and monitor your recovery.

6. Choose a Medicare-Approved Home Health Agency

Not all home health agencies are created equal, and not all are approved by Medicare. To ensure your care is covered, you must choose a home health agency that is Medicare-certified. Here’s how to find one:

• Medicare Website: The official Medicare website has a directory of approved home health agencies.
• Medicare Helpline: You can call 1-800-MEDICARE (1-800-633-4227) to get a list of approved agencies in your area.
• Medicare Advantage Plan Provider: If you’re enrolled in Medicare Advantage, contact your provider directly to find out what agencies are in-network.
• Recommendations: Ask your healthcare provider or local senior centers for recommendations. They can often provide insights into the quality and reliability of different agencies.

Tip: When choosing an agency, consider factors like the agency's reputation, the qualifications of their staff, and the services they offer. Don’t hesitate to ask for references or read reviews from other patients.

7. Understand the Costs

Medicare covers 100% of the cost of home health care services, but there are a few things to keep in mind. If your doctor orders Durable Medical Equipment to be used in home, you will be required to pay your Part B deductible as well as the 20% Part B coinsurance. Your provider will be able to provide exact amounts to you before delivering the DME.

8. Maintain Your Coverage

To keep your Medicare home health care coverage, you need to:

• Remain Homebound: Your condition must still make it difficult for you to leave home without considerable effort.
• Continuing to Need Skilled Care: Your healthcare needs must still require the services of a licensed healthcare professional.
• Regular Reviews: Your healthcare provider must regularly review and update your plan of care. This typically involves a face-to-face evaluation every 60 days or as needed based on changes in your condition.

Tip: Keep in touch with your healthcare provider and home health agency to ensure your plan of care remains up-to-date and appropriate for your needs.

9. Know What Medicare Doesn't Cover

It’s important to know what Medicare does not cover to avoid any surprises:

• 24-Hour Care: Medicare does not cover round-the-clock care or live-in caregivers. If you need 24-hour care, you may need to explore other options, such as long-term care insurance or private pay arrangements.
• Non-Skilled Care: Services that don’t require a licensed healthcare professional, such as shopping or housekeeping, are not covered.
• Custodial care: Personal care services to help with bathing, dressing and using the bathroom are not covered (when this is the only care you need).
• Long-Term Care: Medicare does not cover long-term care services, such as those provided in a nursing home. Long-term care is typically covered by Medicaid or private long-term care insurance.

10. Know Your Rights

As a Medicare beneficiary, you have certain rights when it comes to home health care:

• Choice of Agency: You have the right to choose your own home health agency, as long as it is Medicare-approved
• Detailed Plan of Care: You have the right to receive a detailed plan of care that outlines the services you will receive and how often.
• Informed Consent: You have the right to be informed about your care and any changes to your plan. You should also be involved in the decision-making process regarding your care.

Example: If your home health agency wants to change the frequency of your visits, they should discuss this with you and get your consent.

Conclusion

Qualifying for home health care under Medicare can seem like a complex process, but it’s entirely manageable with the right information and resources. By ensuring you meet the eligibility criteria, choosing a Medicare-approved home health agency, and understanding your rights and responsibilities, you can access the care you need to maintain your health and well-being at home. If you have any questions or need assistance, don’t hesitate to reach out to your healthcare provider or contact Medicare directly. With the right support, you can make the most of Medicare’s home health care benefits and enjoy a higher quality of life in the comfort of your own home.

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Mga Disclaimer

Sources
Medicare.gov - Coverage of Home Health Services
Medicare.gov - Medicare & Home Health Care