The American healthcare system is notoriously fragmented. That makes it difficult for patients, especially seniors, to navigate effectively.
The desire to age in place, to receive necessary medical treatment within the familiar and comforting walls of one's own residence, is a nearly universal preference.
For Medicare beneficiaries, there is good news. You can receive certain home health care services under Medicare, helping you stay safe, supported, and medically cared for without leaving your abode.
In this guide, we’ll walk you through the essential details of Medicare home health coverage.
Medicare home health care is a program designed for patients who need skilled care at home. It is part of the broader Medicare system.
Home health care falls under both Part A and Part B. Part A is hospital insurance. It covers care after a stay in a skilled nursing facility or hospital. Part B is medical insurance. It covers care when a patient has not been in the hospital first.
This benefit allows you to receive high-quality medical treatment in the comfort of your own home. Aurora Home Care notes that home-based care offers a far more affordable alternative to the high costs associated with residential nursing facilities.
Take Philadelphia, for instance. Nearly 20% of the residents of the city are 65 or older. Many of them want to age in place, which is why the demand for in-home support is growing.
Home care agencies typically cost $21.27/hour. Seeking caregivers from a home care agency in Philadelphia that accepts Medicare can make it further affordable. That is because Medicare can help cover the cost of skilled nursing, therapy, and related services that support safe, independent living at home.
Eligibility for home health is governed by four main rules, which we will discuss here:
The most important rule is that the patient must be homebound. This does not require a patient to be bedridden. Rather, it indicates that leaving the home requires significant effort.
Medicare uses a two-prong test to decide if someone is homebound. Under the first prong, the patient must need a device like a cane or walker to leave home. Or, their condition might make leaving home dangerous for their health.
Conversely, the second prong requires the person to have a normal inability to leave home. Also, they must be exhausted after a simple trip.
A patient must need at least one skilled service. Skilled services are things only a professional can do safely. This includes nursing care or therapy.
If a person only needs help with bathing or dressing, they do not qualify. This is called custodial care, which Medicare does not cover by itself. The person must need help from a nurse or a therapist first.
No agency can start care without a doctor's signature. The doctor must certify that the patient is homebound and needs skilled care.
This process includes a face-to-face meeting. This meeting must happen within a specific window. It can be 90 days before care starts. It can also be within the first 30 days of care.
Care must follow a specific plan, called the plan of care (POC). The doctor and the agency work together on this.
The POC lists what services the patient will get. It says how often the nurse or therapist will visit, as well as mentions the goals for the patient’s health. The doctor must review and sign this plan every 60 days to ensure it’s up-to-date.
When the eligibility rules are met, Medicare may cover the following home health services that are medically necessary:
Medicare’s home health benefit is a powerful resource for getting skilled medical care at home, often with little or no out-of-pocket cost.
So, if you’re getting ready to arrange home health care, consult your doctor, ask the agency about Medicare certification and costs. Also, keep a copy of the plan of care. And if anything gets confusing, you can always call the Medicare helpline or reach out to your local SHIP for free, personalized help.
