Medicare and Home Health Services

The Chester County Department of Aging, through its APPRISE program of trained Medicare counselors, helps current and soon-to-become Medicare beneficiaries understand the health care options, specific to their health needs and financial resources. This is one in a series of articles prepared by APPRISE volunteers to help Medicare beneficiaries. The articles, together with the APPRISE Medicare 101 presentations given throughout the year and free one-on-one counseling available at all Chester County senior centers, are designed to help Medicare beneficiaries navigate this complex system.

Recovering from an illness can be a difficult time. Having the availability of Home Health Care can provide you a needed support to progress back to your best level of health.

Home Health Care services were part of the original Medicare law passed in 1965. Services were available on a limited basis then – available only up to 100 days annually. Many things have changed in the world of medicine and now treatments/ services that once were only available in a hospital can now be provided at home. Home health care can not only be less expensive than the hospital, it also can be just as effective. Plus, you are in the comfort of your own home with your family around you.

Currently home health care is available to all Medicare recipients, including those who receive their Medicare through a Medicare Advantage Plan. Medicare pays for these services if you meet certain eligibility criteria and if these services are considered reasonable and necessary for the treatment of your illness or injury. These eligibility criteria must be met to receive home health services:

1. You must be under the care of a doctor who establishes a plan of care for you and reviews this plan of care on a regular basis. A plan of care documents the services and treatments your doctor wants you to have performed in your home.

2. You must need, and your doctor must certify in your plan of care, at least one of the following services on an intermittent basis (less than 7 days/ week, but at least once every 60 days) – skilled nursing, physical therapy, speech therapy or continuing occupational therapy

3. You must receive care provided by a Medicare-certified home health agency. Information on Medicare-certified home health care agencies can be found on the Medicare website using the Medicare Home Health Compare web-

website using the Medicare Home Health Compare website -https://www.medicare. gov/homehealthcompare/ search.html (NOTE: If you receive your Medicare benefits through a Medicare Advantage Plan, you must use the home health agency specified by the plan.)

4. Your doctor must certify in your plan of care

that you are homebound. To be homebound means:

a. You have trouble leaving your home without help (such a cane, walker, or crutches; special transportation; or help from another person) because of an illness or injury, or leaving your home is not recommended because of your illness or injury.

b. You are normally unable to leave your home, but if you do it requires a major effort.

Even if you are defined

as homebound by the above criteria, there are still times you may leave home and still be considered homebound. Such as, you may leave your home for reasons such as a medical treatment or short, infrequent absences for nonmedical reasons like an occasional trip to the barber, a walk around the block, or a drive, or attendance at a family reunion, funeral, graduation or other infrequent or unique event.

You can still be considered homebound if you attend an adult day care program or religious services.

5. Your doctor or certain healthcare professionals that work with your doctor such as nurse practitioner or physician’s assistant, must document that they have had a face-toface encounter with you. This must occur within certain time frames. Faceto-face contact could occur at your primary doctor appointment or as part of a discharge process from a hospital or rehab center.

Should the only service you need be nursing care, and that need is more than the ‘intermittent’ skilled nursing care outlined in the eligibility criteria, you would not qualify for home health services under Medicare.

Medicare coverage for home health services should be equally available to you whether the skilled care you receive is to maintain your current level of independence or to improve an underlying condition. In other words, you

may require skilled home health services to prevent further deterioration or to preserve current abilities, as well as for the treatment of an acute condition.

The types of home health services covered by Medicare include:

Skilled Nursing Care – nurses who provide direct care as well as teach you and your caregivers about your care. Any service that could be done safely and effectively by a non-medical person (or by yourself) without the supervision of a nurse is not considered skilled care.

Physical Therapy, Occupational therapy, and Speech Language Pathology Services – there are specific, safe and effective treatments for your condition and complex enough that they can only be safely and effectively performed by or under the supervision of one of these therapists.

Home Health Aide Services – a part-time or intermittent home health aide to assist with personal services, as needed to maintain your health or assist with exercise plans established by a therapist. You must be receiving skilled nursing or therapy services in order to receive services of a home health aide. Housekeeping services alone are not considered home health aide services.

Medical Social Services – a medical social worker’s visits would be covered if you are also receiving skilled care. Their purpose would be to assist you

with social or emotional concerns that may interfere with your treatment or recovery.

If you meet the eligibility criteria described above, Medicare should cover your home care costs. There are some exceptions which include services and supplies that are never paid for by Medicare, such as routine foot care or housekeeping services. Medicare covered durable medical equipment, such as wheelchairs, walkers or oxygen equipment will be subject to the Medicare Part B 20 percent coinsurance. There are other requirements for payment of durable medical equipment under Medicare Part B which will not be addressed in this article.

Should you be told your home health services are ending, but you feel that you still need services, you have the right to appeal. This can be done by contacting Medicare through their website at

www.Medicare.gov/appeals or you can also call 1-800-MEDICARE (1-800633-4227). If you need a TTY call 1-877-4862048. APPRISE Counselors can assist you with the appeal process.

For more information on Medicare the booklet ‘Medicare & Home Health Care’ (CMS Product Number 10969) is available through the Medicare website www.Medicare.gov

APPRISE counselors are available to answer any Medicare-related questions. You can contact a counselor by calling your local senior center to set up an appointment or leaving a message on the APPRISE help line at 610344-5004. You can also email us with questions at apprisechesco@outlook. com.