How Medi­care Cov­ers Home Health Ser­vices


Acou­ple of years ago, my father, well into his 70s, fi­nally bought him­self a high-per­for­mance au­to­mo­bile.

The kids and grand­kids had all grown up, so there was no need for a larger car. And heck, he had waited a long time to drive some­thing fun.

All was fine with the new car un­til my mother broke her hip, had surgery, and needed ex­ten­sive out­pa­tient phys­i­cal and oc­cu­pa­tional ther­apy.

Get­ting into and out of a sporty car isn’t easy for some­one us­ing a walker and cane. So I got a phone call ask­ing what could be done. (Ac­tu­ally, I think he was an­gling for my new mini­van, whose video screens would give him some­thing to do dur­ing mom’s ther­apy ses­sions.)

But I told him he didn’t need to take mom to a clinic or hos­pi­tal. As a Medi­care ben­e­fi­ciary, she could re­ceive most of the ther­apy in her own home.

Medi­care cov­ers a va­ri­ety of heath care ser­vices that you can get in the com­fort and pri­vacy of your home. These in­clude in­ter­mit­tent skilled nurs­ing care, phys­i­cal ther­apy, speech-lan­guage pathol­ogy ser­vices, and oc­cu­pa­tional ther­apy.

To be el­i­gi­ble for home health ser­vices, you must be un­der a doc­tor’s care and re­ceive ser­vices un­der a plan of care es­tab­lished and re­viewed reg­u­larly by a physi­cian. He or she also needs to cer­tify that you need one or more home health ser­vices.

In ad­di­tion, you must be home­bound and have a doc­tor’s cer­ti­fi­ca­tion to that ef­fect. Be­ing home­bound means leav­ing your home isn’t rec­om­mended be­cause of your con­di­tion, or your con­di­tion keeps you from leav­ing with­out us­ing a cane, wheel­chair or walker; spe­cial trans­porta­tion; or get­ting help from an­other per­son.

Also, you must get your ser­vices from a Medi­care-ap­proved home health agency.

If you meet these cri­te­ria, Medi­care pays for cov­ered home health ser­vices for as long as you’re el­i­gi­ble and your doc­tor cer­ti­fies that you need them.

For durable med­i­cal equip­ment (like a walker or wheel­chair), you pay 20 per­cent of the Medi­care-ap­proved amount.

Skilled nurs­ing ser­vices are cov­ered when they’re given on a part-time or in­ter­mit­tent ba­sis. In or­der for Medi­care to cover such care, it must be nec­es­sary and or­dered by your doc­tor for your spe­cific con­di­tion. Medi­care does not cover full-time nurs­ing care.

Skilled nurs­ing ser­vices are given by ei­ther a reg­is­tered nurse or a li­censed prac­ti­cal nurse un­der an RN’s su­per­vi­sion. Nurses pro­vide di­rect care and teach you and your care­givers about your care. Ex­am­ples of skilled nurs­ing care in­clude: giv­ing IV drugs, shots, or tube feed­ings; chang­ing dress­ings; and teach­ing about pre­scrip­tion drugs or di­a­betes care.

Be­fore your home health care be­gins, the home health agency should tell you how much of your bill Medi­care will pay. The agency should also tell you if any items or ser­vices they give you aren’t cov­ered by Medi­care, and how much you’ll have to pay for them. The agency should give you a no­tice called the Home Health Ad­vance Ben­e­fi­ciary No­tice be­fore giv­ing you ser­vices and sup­plies that Medi­care doesn’t cover.

What isn’t cov­ered? Some ex­am­ples: 24-hour-a-day care at home; meals de­liv­ered to your home; home­maker ser­vices like shop­ping, clean­ing, and laun­dry (when this is the only care you need, and when these ser­vices aren’t re­lated to your plan of care); per­sonal care given by home health aides like bathing, dress­ing, and us­ing the bath­room (when this is the only care you need).

If you get your Medi­care ben­e­fits through a Medi­care Ad­van­tage or other Medi­care health plan (not Orig­i­nal Medi­care), check your plan’s mem­ber­ship ma­te­ri­als. Con­tact the plan for de­tails about how the plan pro­vides your Medi­care-cov­ered home health ben­e­fits.

Greg Dill is Medi­care’s re­gional ad­min­is­tra­tor for Ari­zona, Cal­i­for­nia, Hawaii, Ne­vada, and the Pa­cific Ter­ri­to­ries. You can al­ways get an­swers to your Medi­care ques­tions by call­ing 1-800-MEDI­CARE (1-800-633-4227).

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