In Depth: Home Health Care
Medicare’s home health benefit covers some therapy and skilled nursing services. It is available to individuals who are recovering from an illness or injury, as well as to people with chronic health problems who need skilled care to help them maintain their independence and learn to live with their illness or disability.
In 2006, 2.9 million Medicare beneficiaries used the home health benefit, at a total cost of $13.2 billion.
Eligibility
Scope and Duration of Coverage
Level of Coverage
Provider Payments: Payment to Home Health Providers
For people with Medicare, the program covers home health services when:
- A patient is homebound. That means that leaving home requires “considerable and taxing effort.” Individuals can still be considered homebound if they attend adult day care, or leave home for short periods, such as to go to the doctor or to attend religious services.
- A physician certifies that a patient needs the type of skilled care the program covers. Skilled care that is covered by Medicare’s home health benefit includes part-time or intermittent skilled nursing services, or speech, physical, or occupational therapy.
- A physician approves a care plan for the services needed.
- The services are provided by a Medicare-approved home health agency.
The services covered under Medicare’s home health benefit include the following:
- Part-time or intermittent skilled nursing care, which is care that is provided by or under the direction of a registered nurse. Medicare guidelines define “part-time” as less than eight hours a day. “Intermittent” can be as frequently as daily for up to 21 days (provided there is a predictable point in time when care will end) or as infrequently as once every 60 days. Medicare guidelines provide for coverage up to 28 hours a week without special documentation. With medical justification, coverage may be approved for up to 35 hours a week. To qualify for coverage, the patient must have a condition that requires this level of care.
- Physical, speech, or occupational therapy. Occupational therapy is covered only when part of a care plan includes other types of therapy or skilled nursing care that Medicare covers. Medicare will cover therapy services as long as the physician certifies that they are medically necessary.
- Medical social services that are provided under the direction of a physician.
- Part-time or intermitted services of a home health aide. These services are covered only when they are provided in conjunction with skilled nursing care or covered therapy. When determining the amount of services that will be covered in a particular time period, home health aide and skilled nursing hours are considered together. For example, “part-time” means less than eight hours a day of both skilled nursing and home health services.
- Medical supplies, durable medical equipment, and dressing and wound care supplies.
Medicare covers home health care for patients with a chronic condition as long as they meet the need for skilled care and, for nursing services, as long as their care meets the guidelines for “part-time” or “intermittent.”
Medicare’s home health benefit is covered through Medicare Part A, the hospital benefit, and Medicare Part B, the physician and outpatient services benefit.
Part A will cover the first 100 home health visits after a hospital stay. Medicare Part B covers home health services when there has not been a prior hospital stay. As long as the criteria for Medicare coverage are met, there is no cap on the benefit under Part B.
There is no copayment for services. There is a 20 percent copayment for durable medical equipment.
Medicare pays approved home health agencies using a prospective payment system, like skilled nursing facilities. Home health agencies are paid a predetermined amount based on the health condition and needs of the patient. Payments to agencies are adjusted to reflect geographic differences in wages. Additional adjustments are made for patients who incur unusually high costs.
Medicare pays home health agencies for each 60-day episode of care. If a Medicare patient is still eligible for care after the first 60 days, a second episode of care can begin. Under Medicare’s home health benefit, as long as a patient meets the criteria for home health care, there is no limit on the number of 60-day episodes that will be covered. Payment adjustments are made with each episode to reflect the patient’s health condition.
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