Part 2 in our choices for in-home care services series explains Home Health Care and Medicare services. Home health care involves skilled nursing care or therapy services performed in the client’s home or place of residence. Because this kind of care can be paid with public funds, home health care companies must comply with quality guidelines and are closely regulated.
Medicare, Medicaid and most private insurance plans cover some medically necessary home health care if the client meets certain medical and homebound criteria.
The client must meet all of the four following conditions:
- Their doctor must have determined they need medical skilled care in their home, and the doctor must prepare a plan of care at the home. That plan must be reviewed and renewed by the physician at least every 60 days.
- They will also need to qualify for at least one of the following: intermittent (not full-time) skilled nursing care, or physical therapy or speech language pathology services, or continue to need occupational therapy.
- The client must also be homebound. A hospital or other facility that mainly provides skilled nursing or rehabilitation services does not qualify as a home. They may be considered homebound if they leave their home only with considerable and taking effort. Absences from home must be infrequent, or of short duration, to get medical care or to attend religious services.
- Finally, the home health agency caring for them must be certified and approved by Medicare.
Medicare will pay for the following services for qualified individuals:
- Skilled nursing care either on an intermittent or part-time basis, not full-time. Clients are typically seen by the nurse once or twice a week for about an hour each time, but may be seen more frequently in certain cases.
- CENA services either on an intermittent or part-time basis, not full-time. These services include assistance with personal care such as bathing, using the toilet, and dressing. Clients who qualify for assistance with personal care typically receive up to two hours of care by a CENA per week.
- Physical therapy as often and for as long as the client is progressing towards goals. PT includes exercise to restore and maintain movement and strength to an injured arm or leg, and training in getting into and out of a wheelchair or bathtub.
- Speech language pathology as often and for as remains homebound with a skilled need. This type of therapy includes exercises to restore speech.
- Occupational therapy which is designed to help you to achieve independence in daily living by learning new techniques for eating, dressing and performing other routine tasks.
- Medical social services to assess the social and emotional factors related to your illness, counseling based on this assessment, and searches for available community resources.
- Medical supplies like wound dressings.
- Some medical equipment like wheelchairs, walkers, and oxygen equipment may be partially covered. Many clients will have to pay a co-pay amount for medical equipment.
Medicare will not pay for the following services:
- 24 hour care at home
- Prescriptions drugs—Unless a special plan is purchased
- Meals delivered to the home
- Homemaker services such as shopping, cleaning and laundry, except that HHA’s may do a small amount of these chores when they are providing covered services.
- Personal care provided by HHA’s, such as bathing, toileting, or providing help in getting dressed, if this if the only care the client requires. This type of service is called “custodial” care. Medicare does not pay for custodial care unless the client is also getting skilled care such as nursing or therapy and the custodial care is related to the treatment of the client’s illness or injury.
How long will Medicare services continue?
Medicare will pay for covered home health services for as long as they are homebound and have a skilled need. The skilled nursing and CENA services are paid for only on a part-time or “intermittent” basis. This means there are limits on the number of hours per day and days per week that the client can get these services. To decide whether or not the client is eligible for home health care, Medicare defines “intermittent” as “skilled nursing care that is needed or given on fewer than seven days each week or less than eight hours each day over a period of 21 days (or less).” Once the client is getting the home care services, Medicare uses the following definition of part-time or intermittent to make decisions about the client’s coverage: “skilled nursing or home health aide services combined to total less than eight hours per day and 28 or fewer hours each week.”
*Medicare information collected from AARP and caregiver.com.