Many aging people these days are choosing to continue living at home, choosing to remain independent for as long as possible. As we age, receiving healthcare at home often becomes a more appealing option than moving into an assisted living facility that is unfamiliar.
Home health care is a broad term that includes many types of health care. Some examples of health care that can be provided at home are therapy, skilled nursing care, and custodial care.
However, Medicare doesn’t cover all at-home health care services. Medicare also has strict requirements and qualifications for the services they do cover.
Requirements for Coverage
For home health care to be covered by Original Medicare (Part A and Part B), certain requirements must be met. For instance, your doctor must document that you require either intermittent skilled nursing care and/or some form of therapy.
Your doctor must also create a plan of care, and he/she must review it regularly. In addition to these requirements, you must be certified as homebound, meaning you are unable to leave your home easily.
If you require more than intermittent skilled nursing care or you only need custodial care, then you will not qualify for home health care covered under Medicare. Custodial care is help with activities of daily living such as dressing and feeding yourself. Medicare will only cover custodial care if you are also receiving skilled nursing care.
If you meet all the requirements mentioned above, then Medicare may cover the following:
- Intermittent skilled nursing care
- Intermittent custodial care
- Therapy (physical, speech and occupational)
- Social services
- Medical supplies
- Durable medical equipment (DME)
- Part B medications
Intermittent skilled nursing care means care needed less than seven days a week as well as less than eight hours a day. Medicare also has a 21-day limit for covered home health care. However, if your doctor believes your skilled nursing care will end within a reasonable amount of time, Medicare may extend the limit.
Payment for Medicare Covered Home Health Care
Medicare will pay your home health care agency one payment per episode of care. Your episode of care includes all covered medical services received from your home health care agency for a 60-day period.
As the patient, you will only be responsible for 20 percent of any DME you receive as well as payment for non-Medicare-covered services such as routine foot care, dental, and vision. To learn more about your cost-sharing responsibility under Medicare, visit Boomer Benefits.
You may also be responsible for possible excess charges and services received in coordination with an Advance Beneficiary Notice of Noncoverage (ABN).
To ensure that you get the most cost-effective care, go through a Medicare-approved home health agency. These home health agencies agree to accept Medicare’s approved price for their services as full payment.
What is an Advance Beneficiary Notice of Noncoverage?
Your home health agency should discuss Medicare’s payments and coverage with you both verbally and in writing – the ABN. An ABN is a notice stating that Medicare will likely not cover a certain medical service.
The home health agency is supposed to provide you with an ABN if they believe that the possibility of Medicare covering the service is unlikely prior to give you the service. Reasons, why the agency may give you an ABN, are because the service isn’t medically necessary, the service is only custodial care, your care isn’t on an intermittent basis, and/or you aren’t homebound.
Note that just because you receive an ABN, doesn’t mean Medicare won’t pay. Sometimes, Medicare will pay for your care if they disagree with the ABN. In this case, you will get your payments reimbursed, and Medicare will pay their part.
Home Health Change of Care Notice (HHCCN)
Your home health agency may decide to reduce services or stop them altogether. They may do this due to business-related reasons or if your doctor hasn’t renewed your home health care orders. If the agency does this, it will provide you with an HHCCN. Your agency will also let you know how you can proceed.
If you are unsure why you received an ABN or HHCCN, talk to your doctor. Your doctor may be able to help you contact Medicare to discuss coverage.