Does Medicare cover in-home health care?

In-home healthcare can be incredibly challenging, both in terms of obtaining the proper type and covering the substantial costs. The good news is that Medicare offsets some of these costs. If you are enrolled in either Part A (hospital insurance) or Part B (medical insurance), covered services include:

  • intermittent skilled nursing care
  • physical therapy
  • continued occupational services
  • speech language pathology

Home health coverage may also include:

  • medical social services
  • part time home health aide services
  • medical supplies for home use
  • some injectable drugs
  • durable medical equipment (wheel chairs, powered wheelchairs, scooters, lift chairs)

What does Medicare not cover? When it comes to home health services, 24-hours per day care, delivered meals, homemaker services, and personal care are not covered. These will have to be paid out of pocket.

Eligibility requirements

If you are already enrolled in Medicare Part A or Part B, you will still need to meet a few eligibility requirements. You must be under the care of a physician, and you must be receiving care services established and regularly reviewed by that physician. You must need intermittent skilled nursing care other than just drawing blood. You also must be homebound. However, you are allowed to leave your home for medical treatment or for short absences for non-medical reasons like attending religious services. Your home health agency (the business that coordinates your services and doctor orders) must be certified by Medicare. If you need physical therapy, speech language pathology, or continued occupational therapy services, your doctor must certify that these services are medically necessary for an effective treatment program.

The amount, frequency, and time period of these services must be “reasonable.” The decision of what is reasonable is at Medicare’s discretion. Finally, your eligibility also requires one of the following:

  • Your condition be expected to improve in a “reasonable and predictable” period of time (as determined by Medicare).
  • You need a skilled therapist to develop a maintenance program for your condition.
  • You need a skilled therapist to safely and effectively do maintenance therapy for your condition.

You will not be eligible for Medicare’s home health benefit plan if you need more than part-time or intermittent skilled nursing care.

Durable equipment coverage

Medicare’s website states that Part A or Part B coverage will cost you nothing for home health care services. For durable medical equipment like wheelchairs, powered wheelchairs, scooters, or lift chairs, you’ll usually pay 20% of the Medicare-approved amount for each piece of equipment. The Medicare-approved amount is usually the maximum value that Medicare assigns to a given piece of equipment. For example, you may need a wheelchair that costs $400 from the manufacturer. However, Medicare has only approved the amount of $300 for that chair. You’ll have to pay the difference of $100 plus 20% of the $300 Medicare-approved amount ($60) for a total of $160.

Contact your doctor and a local home health agency to determine if you have the proper coverage. The agency will tell you how much Medicare will pay as well as if they offer services that Medicare doesn’t cover. The agency should also provide you with a notice called the Home Health Advance Beneficiary Notice before giving you services or supplies that Medicare doesn’t cover.

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