‘Home Care’ is a broad term that includes some services Medicare covers and some services it doesn’t. The term also has different meanings in different states since each state licensing agency has different regulations governing what a home care agency can and cannot do.
However, Medicare is a federal program. This means the rules governing what it will and will not pay are the same across the United States.
Private-Pay Versus Medicare-Covered Services
The terms “private-pay” and “out-of-pocket” generally refer to long-term care services like home care, assisted living, memory care and other senior care services generally not covered by insurance. However, some long-term care insurance plans to cover services like these.
But there is no federal standard across long-term care insurance plans. So, if you have a private, long-term care insurance plan, it’s best to consult your individual plan and agent to determine what services it may or may not cover. Long-term care insurance programs typically require clients to submit paperwork directly to receive reimbursement for services.
On the other hand, there are instances where individuals receiving care at home can qualify for Medicare-reimbursable home health services. We’ll cover those scenarios next.
Qualifying for Medicare Home Health Services
To qualify for Medicare home health services of any kind, an older adjust must meet various criteria. That criterion is as follows:
- The person to whom the services are provided is an eligible Medicare beneficiary;
- The Home Health Agency that is providing services to the beneficiary has a valid agreement to participate in the Medicare program;
- The beneficiary qualifies for coverage of home health services as described in §30;
- The services for which payment is claimed are covered as described in §§40 and 50;
- Medicare is the appropriate payer; and
- The services for which payment is claimed are not otherwise excluded from payment.
Regarding #3 above, Medicare further qualifies ‘home health’ care services in the following way:
“To qualify for the Medicare home health benefit, under §§1814(a)(2)(C) and 1835(a)(2)(A) of the Act, a Medicare beneficiary must meet the following requirements:
- Be confined to the home;
- Under the care of a physician or allowed practitioner;
- Receiving services under a plan of care established and periodically reviewed by a physician or allowed practitioner;
- Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or
- Have a continuing need for occupational therapy.
For purposes of benefit eligibility, under §§1814(a)(2)(C) and 1835(a)(2)(A) of the Act, “intermittent” means skilled nursing care that is either provided or needed on fewer than 7 days each week or less than 8 hours of each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable).
A patient must meet each of the criteria specified in this section. Patients who meet each of these criteria are eligible to have payment made on their behalf for services discussed in §§40 and 50.”
Medicare Home Health Coverage Explained
Simplifying the above, you can think of Medicare’s rules governing home health care in a straightforward way. In order for Medicare to pay for your or your loved one’s care, you must be eligible for Medicare, and your care must be provided by an agency who has a contract with Medicare.
In addition, there are clinical requirements the older adult must meet as described above. Of note, the ‘homebound’ definition Medicare uses isn’t as restrictive as it may seem upon first reading. The Medicare statute uses the following definition for homebound:
“… a condition, due to an illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive device (such as crutches, a cane, a wheelchair, or a walker), or if the individual has a condition such that leaving his or her home is medically contraindicated. While an individual does not have to be bedridden to be considered “confined to his home”, the condition of the individual should be such that there exists a normal inability to leave home and that leaving home requires a considerable and taxing effort by the individual. Any absence of an individual from the home attributable to the need to receive healthcare treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not be disqualify an individual from being considered to be “confined to his home”. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration.
Medicare Home Care Services
There are three common scenarios during which Medicare will cover home care and home health services.
- Short-Term Care After a Serious, Negative Health Event
Medicare covers short-term home health care or a nursing home stay for medical treatment and rehab. To qualify, the Medicare beneficiary typically must have a recent, 3-day qualifying hospital stay, a doctor’s order for skilled care and they must engage this care within 30 days of the hospital stay.
- Additional Short-Term Care for Continued Recovery
After the initial period described above, Medicare may also cover some additional care if your doctor certifies that care as medically necessary. That may include some part-time nursing care and ongoing therapies at home for a limited period of time. This additional benefit also covers some medical supplies like wheelchairs and other medical equipment. The Doctor must re-assess and re-order this treatment every 60 days for the benefit to continue.
- Hospice (End-of-Life) Care
If you or your loved one has a terminal illness (life expectancy < six months), Medicare will cover hospice and respite care in your home, in a nursing home or in a hospice care facility. In addition to covering nursing case for hospice patients, Medicare may also cover some therapy under hospice, medical equipment, prescription drugs, a hospice aide or homemaker, grief counseling, social work services and short-term hospitalization or in-patient care for pain and symptom management.
In summary, Medicare qualifications around home care and home health services are complex. It is important to educate yourself and your loved ones on the particulars so you can make informed decisions about your insurance plan during Medicare’s Annual Open Enrollment period. Or, if you find yourself in the midst of this situation, you can always reach out to the team at CarePods. As part of our monthly service fee, we help our clients navigate the long-term environment.