What Medicare Covers
(Please note, this is a guide only. Check with your local home care agency to get coverage details.)
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.
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 discussion on homebound);
3. The doctor determines the need for home health care, orders services needed, and sets up a home health plan;
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.)
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 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 that therapy is not available in the home.
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."
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.
Non Covered Services
Medicare does not pay for medications, meals delivered to the home, or household services such as laundry, meal preparation, shopping, or other home care services furnished mainly to assist people in meeting personal, family or domestic need (See Sec. 205. 1 and 206.7 of HIM 11).
Plan of Care
There must be a plan of care established and certified by a qualifying physician which contains specificity of orders and a signature of a qualified physician. Also, the plan must be reviewed at least every 62 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 Covered by Medicare:
- Part-time or intermittent skilled nursing care. (This can include up to eight hours of reasonable and necessary care per day for up to 21 consecutive days - or longer in certain "exceptional" circumstances. Requires documentation to justify need and predictable end to service)
- Part-time or intermittent services of home health (nurses') aides.
- Physical Therapy
- Speech Therapy
- Occupational Therapy
- Medical Social Services
- Medical Supplies
- Durable Medical Equipment (80 percent of approved amount)
- Psychiatric Nurse 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 (see Medicare definitions)
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