When a loved one needs more help after an illness, injury, or hospitalization, home health care can make it possible to receive skilled care without leaving home. For caregivers, understanding what Medicare covers can make it easier to know when to ask for help and what questions to bring to the doctor.
Medicare has specific requirements for home health coverage, but some common misconceptions make those requirements seem more restrictive than they are. Here are some of the most common myths about Medicare home health coverage and what caregivers should know.
In This Article
- Does Medicare Only Cover Home Health After Surgery or a Hospital Stay?
- Does Medicare Only Cover Therapy That Improves a Patient’s Condition?
- Does Medicare Cover 24-Hour or Full-Time Caregiving at Home?
- What Does Medicare Home Health Coverage Cost?
- Frequently Asked Questions About Medicare and Home Health Care
- Medicare Covered Home Health Care with Residential
Does Medicare Only Cover Home Health After Surgery or a Hospital Stay?
A hospital stay or surgery can lead to a home health referral, but it isn’t the only reason someone may need care at home. Medicare covers eligible home health services when they are medically necessary to treat an illness or injury and the patient meets the requirements for home health.
Home health may be the next step for someone who needs skilled nursing or therapy to manage a wound, recover from an illness or injury, manage a chronic condition, improve or maintain function, or prevent the patient’s condition from getting worse.
Qualifying for home health isn’t just about needing skilled care; it also depends on meeting Medicare’s homebound requirement. Medicare considers someone homebound when an illness or injury makes it difficult to leave home without help, or when leaving isn’t medically advised, and when leaving normally requires considerable effort.
It’s a common misunderstanding, but being homebound doesn’t mean a patient can never leave home. Medicare allows someone receiving home health to leave home for medical treatments and certain short, infrequent activities. A patient may also attend religious services and still meet Medicare’s homebound requirements. For caregivers, this means an occasional trip outside the home doesn’t automatically rule out home health coverage.
Does Medicare Only Cover Therapy That Improves a Patient’s Condition?
Many caregivers assume therapy is only covered if it’s for improving a patient’s condition, but that’s not entirely the case. Medicare can also cover certain skilled physical, occupational, and speech-language therapy aimed at maintaining a patients current abilities or slowing decline. It’s not just restoring or improving function, home health is covered as long as the therapy requires a skilled therapist to safely and effectively aid in care. That includes therapy intended to restore or improve function after an illness, injury, or hospital stay.
For home health care to be covered, the care has to be tied to a specific, measurable goal in the patient’s plan of care, and it’s reassessed regularly to confirm the skilled therapy is still needed.
Does Medicare Cover 24-Hour or Full-Time Caregiving at Home?
Home health care covered by Medicare and private-duty caregiving serve different purposes. Medicare covers medically necessary skilled services such as intermittent skilled nursing, physical therapy, occupational therapy, and speech therapy when eligibility requirements are met. It may also cover part-time or occasional home health aide services, including help with bathing, dressing, and other daily activities, when the patient is receiving covered skilled care at the same time.
Medicare does not cover 24-hour-a-day care at home or personal care when it’s the only care a person needs. That kind of support is typically provided by a private-duty care company at a cost to the patient rather than through Medicare. A patient who needs help with bathing, dressing, or other daily activities and also needs skilled nursing or therapy may qualify for home health services as part of their plan of care. A person who only needs ongoing help with daily activities generally needs to look at other options for that support.
What Does Medicare Home Health Coverage Cost?
For patients who qualify for Medicare, most covered home health services come at no out-of-pocket cost to the patient. Check with your insurance provider to confirm your specific coverage. There may still be cost-sharing for certain durable medical equipment used at home, which Medicare generally covers at 80% of the Medicare-approved amount after the Part B deductible. Learn more about the requirements for home health coverage.
Medicare Advantage plans have their own coverage rules, so families with Medicare Advantage should check their specific plan before starting care. The home health agency should also explain what Medicare is expected to cover and tell the patient in advance if Medicare may not pay for a particular service or supply.
Frequently Asked Questions About Medicare and Home Health Care
Can a patient with Medicare choose their own health agency?
Medicare says patients have the right to choose their home health agency, although the available choices can depend on the services an agency provides, the patient’s insurance coverage, and whether the agency has availability. Medicare Advantage plans may also have network requirements.
Families can also use Medicare’s Care Compare tool to review home health agencies and compare quality and patient experience information.
How long does Medicare cover home health care?
Medicare covers home health care in 30-day periods, and coverage can continue for as long as a doctor certifies that the patient still meets Medicare’s requirements.
How do I get a referral for home health care?
A doctor or other authorized healthcare provider must certify that the patient needs home health care. Caregivers can start by asking the patient’s doctor whether home health services are needed.
What happens if the patient’s condition or care needs change?
Home health plans are reviewed periodically and can be adjusted as the patient’s needs change. It’s important to communicate changes in the patient’s health to the home health team as soon as they occur.
Medicare Home Health Coverage with Residential
Understanding Medicare coverage is an important part of deciding whether home health is right for a loved one. Residential’s home health team works with patients, caregivers, and the patient’s physician to develop a plan of care based on the patient’s needs and goals.
If a loved one is recovering from an illness or injury, managing a chronic condition, or having more difficulty safely managing everyday life at home, contact Residential Home Health about whether home health is the right next step.