What home health services does the Medicare Home Health Benefit cover?
Medicare will pay for skilled nursing, physical therapy, speech therapy, occupational therapy and home health aide services under certain conditions. A few of these conditions are as follows:
- Patient must be homebound
(*see below, Medicare Homebound Status Criteria)
- Care must be medically necessary
(usually for conditions that are acute and serious vs. chronic and stable)
- Care must be part-time or intermittent
- The patient requires at least one skilled professional service
(nurse, physical therapist, speech therapist)
- Care must be provided by a Medicare-Certified Home Care Agency
- Must have a signed Physician’s Order for requested service(s)
- Services must be delivered in the patient’s primary place of residence
* Medicare Homebound Status Criteria
- Leaving the home would require “considerable and taxing effort.”
Examples: Medical condition or symptoms like dyspnea, weakness, frailty, confusion, pain.
- Needs assistance from another person to leave home or needs use of special transportation
- The patient can leave the home only for infrequent, short absences.
Examples: Medical appointments, short walks, hairdresser appointments, or to attend religious services.
- A person may be temporarily homebound while recovering from surgery, serious illness or trauma.
An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home would require a considerable and taxing effort.
Generally speaking, a patient will be considered to be homebound if they have a condition due to an illness or injury that restricts their ability to leave their place of residence except with the aide of: supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person; or if leaving home is medically contraindicated.
For more information about Medicare prescription drug coverage, visit www.medicare.gov on the web or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
For more information about Medicare health plans, including deductibles, coinsurance, and co-payments, look in your “Medicare & You” handbook (CMS Pub. No. 10050). If you don’t have the “Medicare & You” handbook, you can get a free copy by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can order the handbook online at www.medicare.gov on the web.
Medicaid is health insurance that helps people who cannot afford to pay some or all of their medical bills. Medicaid is available to those individuals that meet the financial eligibility requirements set by their state law. Under Medicaid, like Medicare, there is a Home Health Benefit.
For the most part, the Medicaid Home Health Benefit covers the same services that the Medicare Home Health Benefit covers.
Most private health insurance policies have a Home Health benefit that includes some or all of the services provided under the Medicare and Medicaid Home Health Benefits. Coverage, co-pays, and eligibility requirements are insurance company specific. CareResource Hawaii will work with each insurance company toward the best possible plan for the patient.
Long Term Care Insurance
Many long term care insurance policies will pay for some private duty or personal care services. Certain eligibility requirements need to be met. CareResource Hawaii will work with you to determine whether home care qualifies as a benefit under your plan.
Companion, personal care services and some private nursing services are generally not covered by medical insurance plans. Please contact CareResource Hawaii for a current list of rates.