If you’re eligible for Medicare-covered home health care, Medicare covers the following services if they’re reasonable and necessary for the treatment of your illness or injury:
Skilled Nursing Care
Skilled nursing services are covered when they’re given on a part-time or intermittent basis. In order for skilled nursing care to be covered by the Medicare home health benefit, your care must be necessary and ordered by your doctor for your specific condition. You must not need full time nursing care and you must be homebound. See page 5.
Skilled nursing services are given by either a registered nurse (RN) or a licensed practical nurse (LPN). If you get services from a LPN, your care will be supervised by a RN. Home health nurses provide direct care and teach you and your caregivers about your care. They also manage, observe, and evaluate your care. Examples of skilled nursing care include: giving IV drugs, shots, or tube feedings; changing dressings; and teaching about prescription drugs or diabetes care. Any service that could be done safely by a non-medical person (or by yourself) without the supervision of a nurse, isn’t skilled nursing care.
Home health aide services may be covered when given on a part-time or intermittent basis if needed as support services for skilled nursing care. Home health aide services must be part of the care for your illness or injury. Medicare doesn’t cover home health aide services unless you’re also getting skilled care such as nursing care or other physical therapy, occupational therapy, or speech-language pathology services from the home health agency.
Physical Therapy, Occupational Therapy & Speech-Language Pathology Services
Medicare uses the following criteria to assess whether these therapy services are reasonable and necessary in the home setting:
1. The therapy services must be a specific, safe, and effective treatment for your condition.
2. The therapy services must be complex or your condition must require services that can safely and effectively be performed only by qualified therapists. Section 1: Medicare Coverage of Home Health Care 9
3. One of the three following conditions must exist:
- It’s expected that your condition will improve in a reasonable and generally-predictable period of time
- Your condition requires a skilled therapist to safely and effectively establish a maintenance program
- Your condition requires a skilled therapist to safely and effectively perform maintenance therapy
4. The amount, frequency, and duration of the services must be reasonable.
Medical Social Services
These services are covered when given under the direction of a doctor to help you with social and emotional concerns related to your illness. This might include counseling or help finding resources in your community.
Supplies, like wound dressings, are covered when they are ordered as part of your care. Durable medical equipment, when ordered by a doctor, is paid separately by Medicare. This equipment must meet certain criteria to be covered. Medicare usually pays 80% of the Medicare-approved amount for certain pieces of medical equipment, such as a wheelchair or walker. If your home health agency doesn’t supply durable medical equipment directly, the home health agency staff will usually arrange for a home equipment supplier to bring the items you need to your home.
Note: Before your home health care begins, the home health agency should tell you how much of your bill Medicare will pay. The agency should also tell you if any items or services they give you aren’t covered by Medicare, and how much you will have to pay for them. This should be explained by both talking with you and in writing.
The home health agency is responsible for meeting all your medical, nursing, rehabilitative, social, and discharge planning needs, as reflected in your home health plan of care. See page 19. This includes skilled therapy services for a condition that may not be the primary reason for getting home health services. Home health agencies are required to perform a comprehensive assessment of each of your care needs when you’re admitted to the home health agency, and communicate those needs to the doctor responsible for the plan of care. After that, home health agencies are required to routinely assess your needs.