Who is Eligible for Home Health Care Under Medicare
AMEDISYS-ALABAMA GULF COAST
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Jan 24, 2024
Alabama - Gulf Coast
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Who is Eligible for Home Health Care Under Medicare?
Medicare is a federal health insurance program that serves
as a vital support system for people aged 65 and older. Patients may be
eligible for Medicare earlier if they have certain disabilities, End-Stage
Renal Disease or ALS. Among Medicare’s unique benefits is home health
care, which provides skilled nursing, therapies and other care services to
those with specific health needs.
Basic Eligibility for Medicare Home Health Care Benefits
To be eligible for Medicare home health care benefits, the
patient must meet several key criteria to help determine if the patient’s
condition and home environment warrant home health care benefits.
Patients may be eligible for home health if they meet the
following criteria:
Being Homebound
A patient is homebound if they are unable to leave their
home or must go through considerable effort when doing so, or that leaving home
is not recommended because of their medical condition. Homebound status is
determined by the patient’s primary care physician based on physical
limitations, such as disabilities, surgery recovery, severe illness or
cognitive impairment.
Demonstrating a Medical Need
In addition to being homebound, the patient must require
intermittent skilled nursing care or skilled therapy services.
Physician Approval/Face-to-Face Encounter
The patient’s physician must authorize home health care
services and review the patient’s care plan regularly.
The patient must have the required face-to-face encounter
with their physician within the timeframes required by Medicare. The encounter
must also be related to the primary reason you need home health care.
Choosing Medicare-Certified Home Health Agency
The agency providing care must be certified by
Medicare.
Common Conditions Among Patients Requiring Home Health Care
Home health care services cater to a wide range of
conditions commonly experienced by patients aged 65 and above. These
conditions often require comprehensive care by an interdisciplinary
team.
A few of the conditions commonly found among patients of
home health care include:
- Congestive
heart failure, hypertension and other heart conditions
- Diabetes
and accompanying issues
- Chronic
obstructive pulmonary disease (COPD) and other lung conditions
- Stroke
- Cancer
- Recovery
from total knee or hip or other orthopedic procedures
- Wounds
related to pressure injuries or other conditions
- Chronic
kidney disease
- Dementia,
Alzheimer’s Disease or Parkinson’s Disease
A home health care plan tailored to a patient's needs can
effectively address these conditions, providing the necessary support to
promote well-being, independence and quality of life for patients while helping
to avoid unnecessary hospitalizations.
Circumstances That May Lead to Discharge from Home Health
Care
Several circumstances may negate a patient’s basic
eligibility and lead to the termination of home health care. These factors
include:
- No
longer homebound: The patient’s condition improves to a point
where they are no longer considered homebound by their primary care
physician.
- No
longer requires skilled care: The patient no longer requires
skilled nursing care or therapy services initially determined to be
necessary.
- Patient
reaches established goals: The patient achieves the health goals
established at the beginning of the care plan.
- Patient
desire to discharge home health care services: The patient
expresses the desire to discharge from home health.
Types of Care Covered Under Medicare Home Health Care
Medicare home health care provides a wide range of
skilled nursing, therapy and support services to address the medical
and therapeutic needs of eligible patients depending on their needs.
Skilled nursing care includes:
- Observation
assessment: Nurses conduct a comprehensive head-to-toe assessment
to determine if the patient can receive care safely from home. During
observation and assessment, the skilled nurse evaluates changes in the
patient’s condition and updates the patient’s physician to facilitate
treatment plan changes. This includes monitoring the effectiveness of
medications.
- Hands-on
care: Nurses provide care that requires medical expertise and
training, such as wound care, catheter care, tube feeds, ostomy care,
injection administration and other specialized treatments.
- Teaching
and training: Empowerment guides patients and their caregivers in
managing their own health.
- Medication
administration: Nurses administer prescribed medications
(injections and infusions), excluding oral medication, which is not
covered as a skilled service.
- Psychiatric
nursing: Some home health agencies like Amedisys, in some
markets, offer trained psychiatric nurses for mental
health treatments.
Therapy services include:
- Physical
therapy helps patients manage pain and regain strength and
mobility.
- Speech
therapy assists with speech and language disorders.
- Occupational
therapy aids patients in regaining or enhancing daily living
skills (bathing, grooming, dressing and other self-care activities).
Additional dependent services are available once the patient
has a qualifying need for skilled nursing or skilled therapy services,
including:
- Home
health aides: Aide services assist the patient with hands-on
personal care.
- Medical
social work services: Social workers help resolve social or
emotional problems that impact the patient’s recovery or treatment plan.
Services Not Included in Medicare Home Health Care
It’s important to be aware of services not included in
Medicare’s home health care benefit. Although some of these may be necessary
for your needs, you don’t want to be in a situation in which you expect to have
certain services covered but end up with a significant medical bill. Uncovered
services include:
- 24-hour
care: Home health care is intermittent. Continuous,
round-the-clock care is not provided.
- Oral
drug administration: Oral administration of medication is not
covered.
- Homemaker
services: This includes any non-medical assistance, such as
housekeeping tasks and shopping assistance.
Supplemental Services Outside of the Medicare Home Health
Care Benefit
Although Medicare covers core home health care services,
certain services not covered by Medicare might be essential to a patient’s
well-being. These home and community-based services may vary according to the
patient’s location and program requirements. Patient eligibility is determined
through a patient assessment with approval from a patient's primary care
physician or social worker. Services like these include:
- Meals
on Wheels
- Homemaker
services
- Housekeeping
- Shopping
assistance
These non-medical services are generally funded through
out-of-pocket payments or community resource programs. Patients eligible for
Medicaid or Veterans Affairs (VA) benefits may receive additional support. To
find out more, contact your insurance plan or a home health care agency that
connects patients with these external resources.
Costs for Medicare Home Health Care
Understanding associated costs is crucial for patients and
their families when deciding to elect Medicare home health services.
It’s always important to fully understand the cost of benefits from your agency
of choice, but the following key points are a great place to start:
No Out-of-Pocket Costs for Medically Necessary Services
For eligible patients, Medicare covers the costs of all home
health care services deemed necessary by the physician, ensuring that these
patients do not have to pay out of pocket.
Transparency in Medicare Coverage
The home health care agency is responsible for informing the
patient of all costs associated with Medicare coverage. This level of
transparency allows patients to plan and manage their healthcare expenses.
Partial Responsibility for Medical Equipment
When a patient requires Medicare-covered medical equipment,
Medicare may be responsible for covering 20 percent of the cost.
Work with medical equipment provider to receive an estimate to help anticipate
and manage out-of-pocket expenses.
Next Steps for Home Health Care
If you or your loved one has been diagnosed with a severe or
chronic illness, open communication and timely action can significantly impact
the quality of care and support. Take these recommended next steps if you think
home health care is the right choice:
1. Facilitate open communication.
If possible, encourage your loved one to communicate their
wishes and desires with you and other family members and caregivers. Ensure
everyone involved is aware of your or your loved one’s preferences and goals
for care.
2. Contact an agency for connections to resources.
A reputable agency can facilitate access to necessary
resources. In addition to offering access to essential services, the right
agency can provide comprehensive support for a seamless care experience.
3. Consider agencies with a full continuum of care.
A full continuum of care provides a comprehensive range of
healthcare services that address an individual’s care needs across different
stages of illness or recovery.
Choose an agency that offers a full continuum of care so you
or your loved one can smoothly transition from one program to another, if
necessary. This approach ensures they receive consistent, uninterrupted care
tailored to their care needs.
Severe or chronic illnesses create many challenges, but navigating Medicare home health care benefits shouldn't be one of them.
Contact Amedisys Home Health Care in the South Alabama Area with locations in Bay Minette: 251-580-8236, Brewton: 251-809-1717, Citronelle: 251-866-3261, Foley: 800-763-6382, Mobile: 251-380-0492 and Monroeville: 866-334-0260.
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