How Long Will Medicare Pay for Home Health Care

How Long Will Medicare Pay for Home Health Care: Medicare provides coverage for home health care services under specific conditions and for as long as you meet the eligibility criteria. Below is a table summarizing the key aspects of Medicare’s coverage for home health care, followed by a detailed explanation.

How Long Will Medicare Pay for Home Health Care Overview Table

Aspect	Details
Coverage Duration	Indefinite, as long as eligibility criteria are met and care is recertified every 60 days
Eligibility Criteria	– Must be under a doctor’s care with a certified plan – Require skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy – Be homebound as certified by a doctor – Services must be provided by a Medicare-certified home health agency (HHA)
Services Covered	– Skilled nursing care (intermittent) – Physical therapy – Speech-language pathology services – Occupational therapy – Medical social services – Home health aide services (part-time or intermittent) – Durable medical equipment (80% of the approved amount)
Cost to Beneficiary	– $0 for covered home health services – 20% of the Medicare-approved amount for durable medical equipment
Certification Period	Initial plan of care valid for 60 days; must be recertified by a doctor every 60 days thereafter
Limits and Restrictions	– No limit on the number of benefit periods – Services must be reasonable and necessary for the treatment of an illness or injury

Detailed Explanation

Medicare Coverage Duration

• Indefinite Coverage: Medicare does not impose a specific limit on the length of time it will pay for home health care. Coverage continues as long as you meet the eligibility requirements and your doctor recertifies your plan of care every 60 days.
• Recertification: Every 60 days, your doctor must review and recertify that you still need home health services. This involves assessing your condition and updating your care plan as necessary.

Eligibility Criteria for Home Health Care

To qualify for Medicare-covered home health services, you must meet the following conditions:

1. Under Doctor’s Care:
   • You must be under the care of a doctor who establishes and regularly reviews your plan of care.
   • The plan must detail the services needed and must be certified by your doctor.
2. Need for Skilled Services:
   • You require one or more of the following:
     • Intermittent Skilled Nursing Care: Less than 7 days a week or less than 8 hours each day over a period of 21 days or less.
     • Physical Therapy: Services to restore movement and strength.
     • Speech-Language Pathology Services: Help with speech and language issues.
     • Continued Occupational Therapy: Assistance with daily activities when you no longer need other skilled care.
3. Homebound Status:
   • Your doctor must certify that you are homebound, meaning:
     • Leaving home isn’t recommended due to your condition.
     • Your condition makes it difficult to leave home without assistance (e.g., using a cane, wheelchair, special transportation, or help from another person).
     • Leaving home takes a considerable and taxing effort.
4. Medicare-Certified Home Health Agency:
   • Services must be provided by a home health agency (HHA) that is approved by Medicare.

Services Covered by Medicare

• Skilled Nursing Care:
  • Provided on a part-time or intermittent basis.
  • Must be performed by a registered nurse or licensed practical nurse under the supervision of a registered nurse.
• Therapy Services:
  • Physical Therapy: Exercises and treatments to restore movement.
  • Speech-Language Pathology: Assistance with speech and communication disorders.
  • Occupational Therapy: Help with daily activities and regaining skills.
• Home Health Aide Services:
  • Part-time or intermittent services to help with personal activities like bathing, dressing, and using the bathroom.
  • Only covered if you are also receiving skilled nursing care or therapy services.
• Medical Social Services:
  • Counseling and community resource planning.
• Durable Medical Equipment (DME):
  • Medicare covers 80% of the approved amount for necessary medical equipment like wheelchairs and walkers.

Costs to the Beneficiary

• Home Health Services:
  • $0 Cost: You pay nothing for covered home health care services.
• Durable Medical Equipment:
  • 20% Coinsurance: You are responsible for 20% of the Medicare-approved amount for DME.

Certification and Recertification Process

• Initial Certification:
  • Your doctor must certify that you meet the eligibility criteria.
  • A plan of care is established outlining the services you need.
• Recertification:
  • Occurs every 60 days.
  • Your doctor reviews your condition and updates your plan of care.
  • Recertification is necessary for Medicare to continue coverage.

Limits and Restrictions

• No Cap on Benefit Periods:
  • Unlike some other Medicare services, there is no limit to the number of times you can receive home health benefits, as long as you continue to qualify.
• Medical Necessity:
  • Services must be considered reasonable and necessary for the treatment of your illness or injury.
  • Coverage is not provided for personal care alone if you do not need skilled nursing or therapy services.
• Part-Time or Intermittent Care:
  • Skilled nursing and home health aide services are only covered on a part-time or intermittent basis.
  • Generally defined as fewer than 8 hours per day and 28 or fewer hours per week (up to 35 hours in certain circumstances).

How to Start Receiving Home Health Care

1. Doctor’s Referral:
   • Speak with your doctor about your need for home health services.
   • Your doctor will write an order if they determine you meet the criteria.
2. Choose a Medicare-Certified HHA:
   • You have the right to choose any agency that is Medicare-certified and serves your area.
3. Plan of Care:
   • Collaborate with your doctor and the HHA to develop a personalized care plan.

Tips for Beneficiaries

• Stay in Communication:
  • Regularly update your doctor on your condition.
  • Ensure timely recertification to avoid interruption of services.
• Understand Your Rights:
  • You are entitled to a written notice called the “Home Health Advance Beneficiary Notice” if services are reduced or ended.
• Verify Coverage:
  • Confirm that the HHA and any equipment suppliers are Medicare-certified.

When Medicare May Not Cover Home Health Care

• Non-Skilled Care Alone:
  • Medicare does not cover home health aide services if you do not also require skilled nursing or therapy services.
• 24-Hour Care:
  • Continuous, around-the-clock care at home is not covered.
• Meal Delivery:
  • Medicare does not cover meal delivery services to your home.
• Homemaker Services:
  • General housekeeping or personal services unrelated to medical care are not covered.

Conclusion

Medicare’s home health care coverage is designed to support beneficiaries who need medical care in their homes due to illness or injury. Coverage continues indefinitely as long as you meet the eligibility criteria and your need for care is recertified every 60 days. By understanding the requirements and working closely with your healthcare providers, you can take full advantage of the benefits available to you under Medicare.