Home Health Agencies and Your Medicare Plan

If you have recently undergone surgery or treatment that has made it difficult for you to leave home during recovery, a home health agency (also called home health service) is one option at getting the care you need. While Medicare has traditionally been very restrictive, there are some instances where your benefits can help cover the cost of a home health aide.

How Home Health Agencies Can Help

Home health agencies generally help you by following a treatment plan provided by your doctor, in conjunction with providing some of the health services you need, such as changing bandages, helping with physical therapy or providing other kinds of care. Many of these service providers can also teach you to care for yourself as part of a treatment or long-term health plan.

Original Medicare can provide coverage for a home health agency for a short while as you adjust to a disability or recover from a serious health issue. Home health agencies are a choice for people who often cannot leave their home for medical attention, but still require the help of a nurse or physician.

How Home Health Agencies Are Different From Other Nursing Services

You should know that home health agencies are somewhat different from skilled nursing facilities and custodial care. Skilled nursing care is a type of aid that many people seek after leaving the hospital for an illness, surgery, or life-changing health condition, such as stroke, heart attack or amputation. Skilled nursing care gives patients a chance to recover outside of a hospital but in a nursing facility with registered nurses, doctors, and therapists who can help ensure recovery and treatments get off to a good start. Medicare will normally only pay for up to 100 days in a skilled nursing facility and there are rules about who can qualify for skilled nursing care based off their prognosis, doctor’s orders and how long they were admitted to a hospital before seeking a skilled nursing facility. In many cases, people leave a skilled nursing center before they have fully recovered, but with a plan and the skills to continue improving their health.

Custodial care is often needed for a longer period of time than a skilled nursing facility, and is based more around everyday needs and activities as opposed to a health condition. Custodial care is often sought out for individuals with chronic illnesses or disabilities, who cannot complete daily tasks such as dressing, using the bathroom and getting out of bed on their own. Custodial care is often associated with aging, and is not covered by Medicare if it is the only kind of care you need — because it is not considered a medical necessity.

Home health services differ from both skilled nursing care and custodial care because treatment and assistance is given at home and ordered by a doctor. In most cases, people who utilize home health services cannot or have difficulty leaving their home for treatment.

Who is Eligible For Home Health Agency Coverage?

Medicare is strict about what kind of home health services it will cover. Because of this, you must qualify for coverage based on your health needs — and the home health agency must qualify, too. To be eligible for help from a home health agency:

  • Your doctor must have requested these services for you, along with creating a plan of care that they will regularly review and adjust.
  • You must need some kind of skilled nursing care (beyond drawing blood), physical therapy, speech therapy or occupational therapy.
  • Your condition must be expected to improve within a reasonable amount of time.
  • Your condition must require the help of a skilled therapist to help with recovery activities.
  • The home health agency you select must be Medicare-certified.
  • Your doctor must show that you are unable to leave your home during recovery. If you are able to safely leave your home during this time, you will not qualify for home health agency coverage.

Medicare Coverage for Home Health Agencies

If you require coverage for a home health service, Medicare will pay for services that you need, such as therapy, doctor’s visits and medical attention you receive. If you need medications administered by a skilled aid, these will be covered by Medicare Part B. Any medications you that you can take by yourself will be covered by your Medicare Part D prescription drug coverage plan.

But, there are some home health agency services that Medicare simply will not pay for. These are generally tasks that focus more on assisting you with daily or home tasks instead of putting emphasis on your bodily care. In these cases, Medicare will not cover:

  • 24-hour care, available at your home around the clock
  • Homemaker services for tasks such as cleaning, meal preparation, shopping and laundry
  • Meals delivered to you at home
  • Personal care services such as helping you bathe, dress, get out of bed and using the bathroom

Covering the Cost of Home Health Services

Medicare will cover the cost of home health services for as long as your doctor requires them. Often times, this is expected to be a short while as you adjust and recover, and are expected to soon regain the ability to leave your home.
Because home health services can be costly, it is important to confirm that your selected agency is Medicare-certified. If a home health agency is not Medicare-certified, you can be stuck with the full bill for all services you have received. Before your home health services begin, the agency should explain your costs — both what Medicare will pay and what your remaining balance will be. The home health provider should also give you a “Home Health Advance Beneficiary Notice” which outlines the kinds of care and supplies that Medicare will not cover. If any of your treatments or medical items is not covered by Medicare, the home health agency should let you know beforehand so that you can make additional arrangements.

With Original Medicare, much of your home health care cost should be covered. In most cases you will simply pay 20% of the amount for any durable medical equipment you may need (such as wheelchairs or hospital beds) while Medicare picks up the remaining 80%.  Still, in some situations, Medicare may not be able to cover all of your expenses. If this is the case, benefits from a private health plan may be able to pick up where Medicare dropped off.