Data shows that 77% of older adults say they want to stay in their home long-term as they age. As health declines and decisions need to be made, honoring our loved one’s wishes becomes increasingly tricky. One option of care is Medicare-funded Home Health Care.
The Home Health Benefit is a portion of the Medicare program, a federal program covering Americans age 65 or older or those with End-Stage Renal Disease. It is utilized when a person needs skilled care or rehabilitation. If a person has Medicare Part A or Medicare Part B, they may qualify for the Medicare Home Health benefit’s extra assistance.
So, how can you qualify for home health care under medicare?
How do I Apply for Medicare Home Health Care?
A physician or allowed practitioner must certify that you meet Medicare home health care requirements to use this Medicare benefit. The senior must need:
· intermittent skilled nursing,
· occupational therapy,
· physical therapy, or
· speech therapy
These services must be deemed medically necessary to maintain or improve health.
You also need to be considered home-bound. Home-bound means it is increasingly difficult to get out of the house; it does not mean you can’t leave your home. It just means it is difficult to get out of the home due to the need for a walker, cane, wheelchair, or the inability to drive. Essentially, you would have to depend on someone else to bring you to an appointment.
Let’s explore what these services mean.
Services – One or More Required to Qualify for Medicare Home Health
Once you have seen your physician, they will certify that you require one or more of these services to maintain or improve health. The doctor will make a plan of care showing the following services that are needed:
Intermittent Skilled Nursing – Medicare covers nursing care when skills need to be performed by a medical professional such as a Registered Nurse (RN). Examples of these skills are:
- care of illness or injury requiring dressing changes
- IV administration
- tube feeding
- administration of certain injections
- education about medications
- diabetes care
A Licensed Practical Nurse (LPN) or home health aide is included under skilled care as long as a Registered Nurse oversees the care. The care must be fewer than 8 hours a day or fewer than 28 hours per week – in rare cases; they can go up to 35 hours.
Occupational Therapy (OT) – An OT is required when a person has an illness or injury that causes them to lose primary function, or they need to learn to use adaptive equipment. For an older adult, these may be skills like using a tool to help button a shirt, learning how to use a cane or wheelchair, or maintaining a hobby. An OT teaches older adults how to change their movements to take care of themselves effectively, maintain health, and function in their own homes longer.
Physical Therapy (PT) – Older adults tend to experience decreased overall strength, have balance difficulties, and have a slower response time as they age. A PT considers these unique obstacles and plans a program to help prevent muscle wasting and retain function. While most inpatient PT is billed to Medicare Part A, outpatient or home therapy falls under Medicare Part B.
Speech therapy – This is called Speech-Language Pathology and is prescribed for the older adult who has had a stroke or other neurological disorder. Although, in natural aging, an older adult can develop swallowing, speech, language, or memory difficulties. A Speech therapist will work to regain or maintain these functions.
What Home Health Care with Medicare Does Not Cover
- 24-hour supervision
- The care must not exceed the 8 hours a day or 28 hours per week as stated previously.
- Preparing of meals or delivery of meals
- This is not a Medicare-covered benefit, but there are things to help a senior with meals – A local program in my area is the Meals on Wheels Program.
- Daily tasks such as cleaning, laundry or shopping
- There are programs to help with daily tasks. In the area where I live, we have senior helpers that volunteer to aide seniors with occasional help. To find options in your state, take a look at the Elder Directory.
- Personal care like toileting or bathing
- Sometimes, a nursing assistant can be a covered benefit – under the skilled nurse care benefit – allowing personal assistance with bathing.
Know What is Covered in the Medicare Home Benefit
Careful study of your state’s Medicare Benefits and the home health agency providing the services is required. Request a Notice of Non-Coverage (ABN) from the agency that you are receiving care from to further understand any services they provide that are not covered under Medicare guidelines.
What is a Notice of Non-Coverage (ABN)
A home health agency is required to give you a written ABN notifying you of any services that Medicare won’t cover. The services may be deemed medically unnecessary, or a particular supply is not covered. The ABN will show if services are not covered because:
· You are not considered home-bound.
· You do not need skilled nursing care, only help with personal care – which can be provided by non-skilled nursing.
· You need skilled care more than just on an intermittent basis.
· The care is not medically reasonable or essential.
Recertification of Home Health Services
A person qualifies for the Medicare Home Health for a certification period of 60 days. Toward the end of this period, a physician will recertify a person for another 60 days or decide they no longer qualify. There is no limit to amount of times that a person can recertify, as long as they continue to meet medical necessity requirements.
Navigating Medicare Coverage
Navigating Medicare coverage and qualifications can be challenging. Coverage can vary by the older person’s area, and depending on other factors such as VA benefits or other Retirement Benefits, it can be further complicated. It is not a one-size-fits-all. To further understand the Medicare Home Health Benefit, refer to the Medicare & Home Health Care Booklet.
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