There is a significant difference between home health care and personal care services rendered by an unskilled caregiver that are medically required. To assess who is eligible for Medicare-covered in-home services, recognizing the distinction between these two levels of treatment is important.
Medicare is covered only by home health care services prescribed by a physician and delivered by qualified nurses, although patients must meet strict eligibility criteria.
Individuals must be covered by Part A of Medicare (Hospital Insurance) and/or Part B of Medicare (Medical Insurance) and meet the four requirements set out by Medicare.gov:
1. A Medicare-certified home health care provider must provide home health care services.
2.Eligible recipients must be accredited as homebound by a physician.
This means that, because of dependency on mobility aid (e.g. cane, wheelchair, or walker), special transportation, or the assistance of another person to do so, it needs a substantial and taxing effort to leave the house. To be deemed homebound, a person does not have to be bedridden and can still qualify even if they are able to leave home for medical treatment, daycare for adults, and brief, rare non-medical outings, such as worship services and family gatherings.
3. Qualifying beneficiaries must be under the care of a physician.
A course of care that includes medically required services for the treatment or maintenance of a health condition must be recommended by the doctor. This treatment is meant to be short-term, so every 60 days, the doctor is expected to re-certify the plan of care.
4. Qualifying beneficiaries must have a certificate of need from the doctor for at least one of the following services:
Intermittent skilled nursing care
Intermittent means part-time treatment required "less than seven days a week or less than eight hours a day for a span of three weeks or less." Under exceptional cases, there are several exceptions, but extra care would usually not be provided by Medicare.
Skilled therapy services
Physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT) may provide these services, and they must be performed by a licensed therapist. Services may be necessary in order to enhance the condition of the patient within a reasonable and somewhat consistent period of time, to establish an initial condition maintenance program, or to participate safely and efficiently in a properly monitored and instructed maintenance program.
The primary aim of the home care program of Medicare is to offer short-term skilled treatment to seniors in the comfort of their own homes as an alternative to rehabilitation in a hospital or qualified nursing facility.
Professional nursing services, such as a Registered Nurse ( RN) or a Licensed Practical Nurse (LPN), are those that must be offered by a trained health professional.
Examples of such services are:
Professional therapy services are those that must be given by a licensed physical therapist, occupational therapist, or speech-language therapist or under the supervision of a licensed one.
It is necessary to remember that the above facilities will be covered only if they are considered to be unique and appropriate therapies or methods of maintenance for the condition of a patient. In addition, the qualifying frequency and length of the treatments will be dictated by Medicare guidelines. Once the standard of treatment reaches eligible part-time or "intermittent" treatment, Medicare is no longer an option for payment. In the eyes of Medicare, home health care facilities are intended to avoid or postpone, not fully substitute, placement in an assisted living or qualified nursing facility.
If those are the only required services, Medicare will not pay for unskilled home care. Personal home care services (assistance with daily life activities) or home-building services ( e.g. light housekeeping and laundry) may be provided only if they are part of the specialized services listed in the care plan. Medicare does not cover the home treatment of any sort or meals provided to the home around the clock.
Eligible seniors would pay zero for home health care services that are ordered by a doctor and delivered by a licensed home health agency with original Medicare coverage (Part A and/or Part B). There will be no compensation for any extra services rendered outside of the approved care package and must be charged out of pocket.
Be aware that the home health provider should have an itemized receipt or schedule of treatment before services begin that defines what is qualified and what is not eligible for Medicare coverage. An “Advance Beneficiary Notice of Noncoverage” (ABN) written notice would outline any facilities and durable medical devices that Medicare will not pay for, as well as the expenses for which the patient will be liable.
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