Benefit Bulletin: August 2013

Benefit Bulletin: August 2013

Are You Eligible For Medicare's Home Health Services?

Medicare covers home health services for eligible homebound seniors and disabled people. But to qualify, beneficiaries need to carefully follow the requirements. Here are the three things needed to qualify.

  1. Is the beneficiary homebound? Currently, homebound means that the beneficiary must be confined to a home and leaving the residence requires a considerable and taxing effort. Absences from the home must be infrequent, or for periods of relatively short duration, or to receive medical treatment. Beneficiaries can still get home healthcare if they attend adult day care.
  2. The beneficiary must need part-time or intermittent skilled nursing care and/or skilled rehabilitation. Medicare covers home health services up to seven days a week for no more than 8 hours per day and 38 hours per week. Medicare pays for skilled nursing care that requires a registered nurse (RN) or licensed nurse under the supervision of an RN. Injections, tube feedings, catheter changes, observation and assessment of a patient's condition, are examples. Beneficiaries requiring skilled rehabilitation services like physical therapy, speech services, and occupational therapy, may be eligible if the services are reasonable and necessary to treat or maintain function affected by their illness or injury. If a patient requires skilled services then Medicare also pays for a home health aide to provide personal care services, including help with bathing, toileting and dressing. If the beneficiary ONLY requires personal care, then he or she does NOT qualify for the home care benefit.
  3. Beneficiaries must be under the care of a physician and need reasonable and necessary home health services. Very important! The services need to be certified by a physician and established in a 60-day plan of care.

Currently, beneficiaries with original Medicare and Medigap plans pay no cost sharing for eligible home health services, and 20% of the Medicare-approved amount for durable medical equipment like walkers or wheel chairs. Medicare Advantage plans may charge a co-payment for services.

About one out of ten Medicare beneficiaries uses home health services every year. Congress is currently considering President Obama's proposal to create a new $100 copay per home health episode (about 60 days). TSCL opposes this increase because it shifts a greater portion of spending to the oldest and sickest seniors and disabled people. TSCL surveys indicate that when seniors feel they can't afford healthcare, they forego necessary care. The president's proposal does nothing to address rising home health costs that are growing 35 percent faster than other Medicare services.

Tip: Before hiring, make sure the agency is certified by Medicare. The agency should explain what Medicare covers and what you or your health plan must pay. Be sure to get this explained in writing. The home health agency should give you a notice called the Home Health Advance Beneficiary Notice before giving you services and supplies that Medicare doesn't cover.

To learn more about Medicare home health services, visit Medicare Interactive is an online tool provided by the Medicare Rights Center (MRC), the largest independent source of healthcare information and assistance in the United States for people with Medicare.

Sources: Medicare Home Health Benefit Primer: Benefit Basics and Issues, Scott R. Talaga, Congressional Research Service, March 14, 2013, R42998. "Medicare Overhaul Won’t Be Easy, House Panel Hears," Emily Ethridge, CQ Roll Call, May 21, 2013.