What Medicare Covers

Medicare pays for the full cost of medically necessary home health care including: Nursing, Home Health Aide, Medical Social Work, Occupational, Speech and Physical Therapies, home-based Psychiatric Nurse Services and medical supplies.

(Please note this is a guide only.  Check with your local home care agency to get coverage details.)

General Requirements for Home Health Care

Medicare Part A pays the entire cost of all medically necessary home health visits for those 65+ or disabled if:

1. The care needed includes part-time skilled (intermittent) nursing care, physical therapy or speech therapy;

2. The patient is essentially homebound (see below);

3. The doctor determines the need for home health care, orders services needed, and sets up a home health plan; and

4. The home health agency providing services is participating in Medicare.

Part Time/Intermittent Care

Under the Balanced Budget act of 1997, part-time or intermittent Skilled Nursing Care means skilled care that is either provided or needed on fewer than seven days each week or less than eight hours of each day for periods of 21 days or fewer (with extensions in exceptional circumstances when the need for additional care is finite and predictable.)

Homebound

The homebound patient is unable to leave home without great effort. When she/he does, it is rare and only for a short period or done in order to receive medical care. The HIM 11 (Medicare's rules guidebook) says: "The conditions of these patients should be such that there exists a normal inability to leave home and consequently, leaving their home would require a considerable and taxing effort". A patient is homebound if he/she is unable to leave the home without:

1. supportive devices (walker, cane, crutches, wheelchair); or

2. use of special transportation; or

3. the assistance of another person; or

4. if the patient's condition dictates that leaving the home is medically contraindicated.

(Additionally for psychiatric patients even with no physical limitation, the patient is considered homebound if the illness is manifested by a refusal to leave home or if it would be unsafe for the patient to leave.)

The patient is considered homebound under Medicare if his/her absence from the home is for dialysis, chemotherapy, radiation or other medical treatment. The patient may also attend an adult day care when the purpose is to receive medical care. The patient may go to outpatient therapy if in-home therapy is not available.

Psychiatric Nurse Services

Psychiatric Nurse Services in the home are covered when all the criteria for eligibility for Home Health coverage are met, the services ordered are "reasonable and necessary for the treatment of the patient's condition and require the skills of a psychiatrically trained nurse."

Therapies

If on-going physical, occupational, or speech therapy visits are to be made, the patient must have "restorative potential". If a restorative program is not appropriate, Medicare may cover an evaluation visit, visits to manage the care plan and visits to develop a maintenance program. In addition, Medicare B pays 80 percent of the approved cost of "durable approved" equipment such as wheel chairs, in-home hospital beds and so on.

Plan of Care

There must be a plan of care established and certified by a qualifying physician that contains specificity of orders and a signature of a qualified physician. Also, the plan must be reviewed at least every 60 days. If any services are provided based on a physician's verbal order, the orders must be put in writing, and be signed and dated with the date of receipt by the RN or qualified therapist responsible for furnishing or supervising the ordered services.

Home Health Services Not Covered by Medicare:

·        24-hour-a-day nursing care at home

·        Drugs and biologicals

·        Meals delivered to your home

·        Homemaker services

·        Blood transfusions

·        More than eight hours per day of combined nursing/aide

·        Non-skilled nursing services

Hospice Care (Medicare/Medicaid)

A Hospice is a public agency or private organization that is primarily engaged in providing pain relief (palliative care), respite care, symptom management, and supportive services to terminally ill people and their families.

Hospice care is a special type of care for people who are terminally ill. It includes both home care and inpatient care, when needed, and a variety of services not otherwise cover-ed under Medicare.  Under the Medicare hospice benefit, Medicare pays for services every day and also permits a hospice to provide appropriate custodial care, including home-maker services and counseling. Medicare Hospice also covers necessary medications and durable medical equipment.

Who is Eligible?

Medicare/Medicaid coverage for hospice is available only if:

• The patient is eligible for Medicare Part A or Vermont Medicaid.
• The patient's doctor and Hospice Medical Director certify the patient is terminally ill with a life expectancy of six months or less.
• No further aggressive or cure-oriented treatment is desired or recommended.
• The patient and family understand hospice philosophy and the patient signs a statement choosing hospice care instead of standard Medicare or Medicaid benefits.

 Hospice Covered Services 

• Nursing services
• Physician services
• Medication necessary for pain control and symptom management
• Medical Social Services
• Trained volunteers to provide respite, family assistance and support
• Home health aide and homemaker
• Medical supplies and appliances
• Short-term inpatient care of pain control and symptom management
• Respite care for up to five days to give temporary relief.
• Counseling for patients and family
• Physical, Occupational and Speech Therapy

 Hospice Benefits Periods

 The Medicare benefit is fairly complicated and is divided into several benefit periods. At the beginning of each benefit period, the physician must certify that the patient has a prognosis of six month or less to live.  The benefit periods may be used consecutively or at intervals.

 Hospice Private Insurance

 Most private insurance plans also include a hospice benefit. The rules for eligibility and the benefits offered differ for each plan.