Medicare Coverage of Home Health Services

Medicare will help cover home health care costs for beneficiaries who meet the following four (4) conditions:

Your doctor must decide that you need medical care at home, and make a plan for your care at home;
You must need at least one of the following: intermittent skilled nursing care, or physical therapy or speech-language therapy or continue to need occupational therapy;
You must be home bound. This means that you are normally unable to leave home unassisted. Being homebound means that leaving home is a major effort. When you leave home, it must be to get medical care, or for short, infrequent non-medical reasons such as a trip to get a haircut, or to attend religious services or adult day care.
The home health agency caring for you must be approved by the Medicare program.

If you meet all of the conditions above, Medicare will help cover:

Skilled nursing care on a part-time or intermittent basis. Skilled nursing care includes services and care that can only be performed safely and correctly by a licensed nurse (either a registered nurse or licensed practical nurse).
Home health aide services on a part time or intermittent basis. A home health aide does not have a nursing license. The aide provides services that give additional support to the nurse. These services include help with personal care such as bathing, using the toilet or dressing. These types of services do not need the skills of a licensed nurse. Medicare does not cover home health aide services unless you are also getting skilled care such as nursing care or other therapy. The home health aide services must be part of the home care for your injury or illness.
Physical therapy, speech-language therapy and occupational therapy for as long as your doctor says you need it.
- Physical therapy, which includes exercise to regain movement and strength to a body area, and training on how to use special equipment or do daily activities, like how to get in and out of a wheelchair or bathtub.
- Speech-language therapy (pathology services), which includes exercise to regain and strengthen speech skills.
- Occupational therapy, which helps you to become able to do usual daily activities by yourself. You might learn new ways to eat, put on clothes, comb your hair, and new ways to do other usual daily activities. You may continue to receive occupational therapy even if you no longer need other skilled care.
Medical social services to help you with social and emotional concerns related to your illness. This might include counseling or help in finding resources in your community.
Certain medical supplies, like wound dressings, but not prescription drugs.
Certain medical equipment, such as a wheelchair or walker. Medicare usually pays 80% of the approved amount for some medical equipment.

Extending Medicare Coverage of Home Health Services

The doctor decides whether medical care is needed at home and makes a plan for that care. The Home Health agency also assesses the patient's health care needs and coordinates with the patient's doctor. While the patient is receiving home care they must continue to need those services at a level that is covered. This means that if they are becoming more independent in self-care it could be determined that they may no longer be eligible to receive home care.

The Home Health Agency must provide you with a written notice stating when services will be discontinued. This notice is called a Home Health Advance Beneficiary Notice. If the patient or the family caregiver feels that services should continue they should read the notice carefully, indicate their decision and ask the Home Health Agency to "demand" bill Medicare for the services provided after the date on the notice.

If the patient or family wish the care to continue while waiting for the Medicare decision on coverage they should ask about the cost of these services and understand that they will have to pay the cost of the services if Medicare considers those services not eligible for coverage. If it is decided not to continue the home health services, discuss any available options with the Home Health Agency and/or the doctor.

Persons enrolled in Medicare Advantage Plans or those enrolled in the original Medicare Plan have access to "fast track" or quick appeals process if they have been notified that services they have been receiving may be reduced or terminated and they disagree. This process applies to services provided by Home Health Agencies, Skilled Nursing Facilities or Comprehensive Outpatient Rehabilitation Facilities.

To access information about Fast Track or other appeals, call 1-800-Medicare (1-800-633-4227).

In New York State, to receive information or to file for a Fast Track Appeal call the following numbers:

Medicare Advantage Plan Enrollees 1-800-696-9561
Original Medicare Enrollees: 1-800-833-0356

* These lines are available 7 days/ week from 8:30 am - 4:30 pm.

Call the Eldercare Locator 1-800-677-1116 to find what other services may be available in your community at moderate or low cost.