5 requirements to qualify for Medicare Home Health Care

You are doing everything you can for your aging loved one, but sometimes it comes to the point where that is not enough. After a hospitalization, or to simply maintain or slow the decline of their health, some older adults may need care from skilled therapists and nurses. This new twist in caring for your loved one raises many questions: How will you afford these professionals? What about Medicare? And, perhaps most importantly, who qualifies for Medicare Home Health Care benefits?  

“Medicare pays for skilled services, such as nursing and therapy in the home, when there is a skilled need and the patient is homebound,” says Jeanmarie Kineiko, a registered nurse and administrator of the Gurwin Certified Home Health Agency in New York.

How do you know if you or a loved one qualifies for these vital Medicare Home Health Care benefits? Here’s a closer look at the requirements and expert tips to know when you’re seeking coverage.

How to qualify for home healthcare under Medicare

In order to qualify for Medicare Home Health Care benefits, the following five requirements must be met:

1. You or your loved one are under a doctor’s care

Patients seeking Medicare Home Health Care benefits must be under the care of a doctor or other healthcare provider (such as a nurse practitioner, a clinical nurse specialist or a physician assistant). Additionally, medical services must be carried out as part of a care plan established and reviewed regularly by that provider.

2. You or your loved one require at least one of the approved medical services

The doctor or healthcare provider must certify that the intended Medicare recipient needs one of the following:

• Intermittent skilled nursing care (other than drawing blood).
• Physical therapy.
• Speech-language pathology services.
• Continued occupational therapy.
• Home health aide services.

3. The home health agency providing care is approved by Medicare

You and your loved one have a say in which agency you use, but choices could be limited by agency availability or insurance coverage. For example, if you have a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan, it may require that you get home health services from agencies they contract with.

All Medicare-certified home health agencies (CHHAs) accept Medicare benefits, Kineiko says. Additionally, home health agencies are certified to make sure they meet certain federal health and safety requirements.

You can compare home health agencies in your area by the types of service they offer and the quality of care they provide at Medicare.gov/homehealthcompare.

4. A doctor certifies that you or your loved one are homebound

“Medicare covers 100% for services when there is a skilled healthcare need following an acute episode such as hospitalization or change in health status as long as the patient is homebound,” Kineiko says.

To be homebound means:

• You have trouble leaving home without assistance (such as a cane, wheelchair, walker, crutches or special transportation).
• Your mobility is limited due to an illness or injury.
• Leaving home is not recommended because of your condition.

To be eligible for Medicare Home Health Care benefits, your doctor or health provider must certify that the above is true. Typically, those who are homebound may still leave home for medical treatments.

5. A doctor has met with you or your loved one face-to-face

As part of your certification of eligibility, a doctor or other healthcare professional must document that they’ve met two requirements:

• They’ve had a face-to-face encounter with you within required time frames.
• The encounter was related to the reason you need home healthcare.

Who qualifies for Medicare Home Health Care services?

Those enrolled in Original Medicare can use both Part A and Part B to cover limited home health services. With Medicare Advantage, the benefits offered for home healthcare vary widely from plan to plan. Check your coverage and work closely with your healthcare team to understand what benefits you may be eligible for.

Keep in mind, people generally don’t qualify for Medicare Home Health Care benefits if they require more than “intermittent” care. Intermittent care is defined by Medicare.Gov as skilled nursing care that’s needed:

• Fewer than seven days per week.
• Less than eight hours each day for up to 21 days.

Medicare may cover a percentage of the cost of continuous healthcare, but it does not cover 24-hour home care, home meal delivery or home aides that solely help with Activities of Daily Living (ADLs) such as bathing, dressing and meal prep.

The bottom line

Medicare Home Health Care benefits are a strong option for those who require intermittent skilled care and meet certain eligibility factors.

You also may be comforted by the fact that your loved ones have rights as far as their healthcare is concerned. These include having their property treated with respect; to be told, in advance what care they’ll be getting and when their plan of care is going to change; and to participate in their care planning and treatment. They also have the right to file a complaint about the quality of their home healthcare if they aren’t satisified.

To learn more about Medicare and healthcare requirements, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) for questions about benefits.

Original article written by Dana Klosner-Wehner.