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Senior Lifestyles

How Medicare covers home health services

A couple 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. I told him that 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, including intermittent skilled nursing care, physical therapy, speech-language pathology services and occupational therapy.

Such services used to be available only at a hospital or doctor’s office. But they’re just as effective, more convenient and usually less expensive when you get them in your home.

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. The doctor must certify that you need one or more home health services.

• 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 special transportation, help from another person or use of a cane, wheelchair or walker.

• 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 – such as a walker or wheelchair – you pay 20 percent of the Medicare-approved amount.

Skilled nursing services are covered when they’re administered on a part-time or intermittent basis. 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.

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

What will Medicare pay for?

Before your home health care begins, the home health agency should tell you how much of your bill Medicare will pay. The agency also should tell you which items or services Medicare doesn’t cover, and how much you’ll have to pay for them.

This should be explained both by talking with you and in writing. The agency should give you a notice – the Home Health Advance Beneficiary Notice – before administering services and supplies Medicare doesn’t cover.

What isn’t covered? Some examples:

• 24-hour-a-day care at home

• Meals delivered to your home

• Household services such 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 – 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 administrator for details about how the plan provides your Medicare-covered home health benefits.

If your doctor decides that you need home health care, you can choose from among the Medicare-certified agencies in the area. However, Medicare Advantage or other Medicare plans may require that you get services only from agencies they contract with.

One good way to look for a home health agency is by using Medicare’s “Home Health Compare” Web tool, available at medicare.gov/hhcompare. It enables users to compare agencies by the types of services they offer and the quality of care they provide.

For more information on Medicare’s home health benefit, access the booklet “Medicare and Home Health Care” at medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf.

Greg Dill is Medicare’s regional administrator. For more information, call (800) 633-4227.

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