Because many people on Medicare require additional help at some point it is important to understand Medicare and home healthcare coverage. The main goal of home healthcare is help individuals recover from an illness or injury and regain independence.
Eligibility
In order for a beneficiary to qualify for home healthcare services under Medicare, the following criteria must be met:
- A doctor or another licensed healthcare provider must have a face-to-face meeting with the beneficiary and certify that they require home health services.
- The beneficiary must require part-time/intermittent skilled nursing care, physical therapy, occupational therapy or speech-language pathology services.
- Patients must be homebound. In other words, it is difficult for them to leave the house without help due to their condition.
- A Medicare certified home healthcare agency must provide the care.
Services Medicare covers
Once the eligibility criteria are met, Medicare covers many home health care services, including:
- Skilled Nursing Care: Provided on a part-time or intermittent basis.
- Therapy Services: Physical, occupational, and speech-language therapy to aid in recovery and rehabilitation.
- Home Health Aide Services: Assistance with personal care on a part-time basis if the patient is also receiving skilled care.
- Medical Social Services: Counseling and help finding community resources.
- Medical Supplies: Certain medical supplies like wound dressings.
- Durable Medical Equipment (DME): This includes equipment such as walkers or wheelchairs.
Services Medicare does not cover
- Full-time care: 24-hour-a-day care at home.
- Meals: Meals delivered to the home.
- Homemaker services: Medicare dose not cover services such as; shopping, cooking or cleaning if they are the only services needed.
- Personal care: If this is the only care required, Medicare will not pay a home health aide to provide basic personal care services such as bathing, dressing or using the bathroom (activities of daily living).
How to set up home healthcare services under Medicare
- Make an appointment with your doctor or healthcare provider to go over your health needs and establish if home health care is a good choice.
- Be sure you see your doctor face-to-face as required by Medicare.
- Ask your doctor or insurance provider to help you find a Select a home health agency that is certified by Medicare.
- Work with your doctor and the home health agency to develop a plan of care to fit your specific needs.
How Original Medicare covers home healthcare costs
In most cases, individuals enrolled in original Medicare pay nothing for covered home healthcare services. Although, there is a cost for DME durable medical equipment. In general, Medicare covers 80% of the approved amount while the individual is responsible for the remaining 20%.
Part A: Typically covers home health care services after the beneficiary has been in the hospital for a period of 3 days or more.
Part B: Covers home health services without the requirement of a prior hospital stay.
Watch a YouTube video the difference between Medicare Supplements and Medicare Advantage
Medicare Advantage Plans and Home Health Care
Medicare Advantage plans (Medicare Part C), are an alternative to Original Medicare. Private insurance companies that are approved by Medicare offer these plans. They must provide the same benefits as Medicare Part A and Part B. Many Medicare advantage plans also offer additional benefits that original Medicare does not cover, such as vision, dental, wellness programs, OTC as well as rides to medical appointments.
How Medicare Advantage plans cover home healthcare costs
Although Medicare Advantage plans must cover at least the same level of home health care services as Original Medicare, there are a few things you should know:
- Network Restrictions: Unlike Original Medicare, Medicare Advantage plans often have network restrictions. Beneficiaries of most plans need to use home health agencies that are in the plan’s network.
- Prior Authorization: Some Medicare Advantage plans require prior authorization for home health services. In other words, beneficiaries need approval from the plan before they receive certain services.
- Additional Benefits: Many MA plans offer extra benefits beyond what Original Medicare provides. These could include additional support services, like caregiver support, home modifications, or wellness programs.
- Cost Structure: Although Medicare Advantage plans must cover home health care at least as well as Original Medicare, the cost structure (copays, coinsurance, and deductibles) may be different. It’s important to understand your plan’s specific costs.
Find out how to cover the gaps left by Medicare advantage plans
Medicare’s home health care coverage can significantly benefit those who need medical care in the comfort of their own home. Understanding the eligibility criteria, the types of services covered, and how to initiate these services ensures that beneficiaries receive the appropriate care while minimizing out-of-pocket expenses.
Please note: before choosing a Medicare plan, it is best to consult a licensed healthcare agent to get accurate, personalized plan information.
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