According to Medicare guidelines, who is eligible for Home Health Care?
Medicare tries their hardest to make it easy to understand what they will, or won’t, pay for when home health care is ordered. Unfortunately, there are still way too many “guidelines” to follow but we are going to offer the following in an attempt to simplify your understanding of what home health care is, and isn’t.
Medicare will pay for home health benefits if you meet ALL of the following:
1. Must be under the care of a doctor, and you must be getting services under a plan of care which is established and reviewed regularly by a doctor.
2. You must need, and a doctor must certify that you need, one or more of the following:
a. Intermittent skilled nursing care (you must NOT need full-time nursing! If you need full-time nursing then a nursing home is a more appropriate setting; or you can pay privately for a nurse at home.)
b. Physical therapy
c. Speech-language pathology services
d. Continued occupational therapy
3. The home health agency caring for you must be approved by Medicare.
4. You must be homebound, and a doctor must certify that you are homebound. To be homebound means the following:
a. Leaving your home isn’t recommended because of your condition.
b. Your condition keeps you from leaving home without help.
c. Leaving home takes a considerable and taxing effort.
What Medicare Covers
Medicare will pay for the following services if they’re reasonable and necessary for the treatment of your illness or injury:
1. Skilled Nursing – If given on a part-time or intermittent basis; ordered by your doctor for a specific condition. (You must NOT need full-time nursing care and you must be homebound. If you need full-time nursing then a nursing home is a more appropriate setting; or you can pay privately for a nurse at home.) Skilled nursing services are given by either a RN, or LPN. Home health aide services may be covered when given on a part-time basis as support for skilled nursing.
2. Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services:
a. Therapy services must be a specific, safe, and effective treatment for your condition.
b. Therapy services must be complex or your condition must require services that can safely and effectively be performed ONLY by qualified therapists.
c. ONE of the following conditions MUST exist:
i. It’s expected that your condition will improve in a reasonable and generally predictable period of time.
ii. Your condition requires a skilled therapist to safely and effectively establish a maintenance program.
iii. Your condition requires a skilled therapist to safely and effectively perform maintenance therapy.
See https://www.medicare.gov/Pubs/pdf/10969.pdf for more information.