Laura LeyvaPatients that are eligible for home health care, are covered under the Medicare Plan for the following services:

  1. Skilled nursing care on a part-time or intermittent basis. Skilled nursing care includes services and care that can only be done safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse). The services must be reasonable and necessary for the treatment of your illness or injury.
  2. Home health aide services on a part-time or intermittent basis. A home health aide doesn’t have a nursing license. The aide provides support services for skilled nursing care. These services include help with personal care such as bathing, using the toilet, or dressing. Medicare doesn’t cover home health aide services unless you are also getting skilled care such as nursing care or other therapy from the home health agency. The home health aide services must be part of the care for your illness or injury

Certain types of therapy for as long as your doctor says you need it. Medicare covers the following:

  1. Physical therapy, which includes exercise to regain movement and strength to a body area, and training on how to use special equipment or perform daily activities, like how to get in and out of a wheelchair or bathtub.
  2. Speech-language pathology services, which includes therapy to regain and strengthen speaking and swallowing skills, as well as listening, reading, and memory skills.
  3. Occupational therapy, which helps the patient learn to do usual daily activities by themselves. The Patient might learn new ways to eat, put on clothes, comb their hair, and perform other usual daily activities. The Patient may continue to get occupational therapy even if you no longer need other skilled care.
    Medical social services under the direction of a doctor to help the patient with social and emotional concerns related to the patient illness. This might include counseling or help in finding resources in your community. Certain medical supplies, like wound dressings, that are ordered as part of your care.

Durable medical equipment, when ordered, is covered separately by Medicare. This equipment must meet criteria for coverage. Medicare usually pays 80% of the Medicare-approved amount for certain pieces of medical equipment, such as a wheelchair or walker. If the 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 the care begins, the home health agency should tell the patient how much of the bill Medicare will pay. The agency should also tell the patient if any items or services they give the patient aren’t covered by Medicare, and how much the patient will have to pay for them. This should be explained both by talking with the patient and in writing.

What isn’t covered by the Medicare Plan? Medicare doesn’t pay for the following:

  1. 24-hour-a-day care at home.
  2. Meals delivered to your home.
  3. Homemaker services like shopping, cleaning, and laundry when this is the only care you need, and when these services aren’t related to your plan of care.
  4. Personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care the patient needs.

Note: If the patient has a Medigap (Medicare Supplement Insurance) policy or other health insurance coverage, be sure to tell the patient doctor or other health care provider so the patient bills can be paid correctly.

  1. What does the patient have to pay?
  2. The patient may be billed for medical services and supplies that Medicare doesn’t pay for (in certain cases the home health agency will give you a notice called the Home Health Advance Beneficiary Notice (HHABN).
  3. 20% of the Medicare-approved amount for Medicare-covered medical equipment such as wheelchairs, walkers, and oxygen equipment.

Home Health Advance Beneficiary Notice

If a home health agency cuts back or stops your services, in most cases, the agency should give the patient a written notice called a Home Health Advance Beneficiary Notice (HHABN).
The HHABN should both describe the items and/or services the agency believes Medicare won’t pay for and explain why they believe Medicare won’t pay.
If a home health agency cuts back or stops your services, the patient may have an option to keep getting the services, even though Medicare isn’t expected to pay for them. The HHABN gives clear directions for getting an official decision from Medicare about payment for home health services and for filing an appeal if Medicare says it won’t pay.
In general, to get an official decision on payment, the patient should keep getting the home health services if the patient thinks they need them. The home health agency should tell the patient how much they will cost. The patient should talk to their doctor and family about this decision. The patient understands that may have to pay the home health agency for these services. The patient has the right to have the agency bill Medicare for their care. If the Medicare Plan decides to pay for the patients care, the patient will get back all of their payments, except for any coinsurance payments the patient made for durable medical equipment.

Dr. Laura Leyva is the CEO/Senior Consultant of Physician Consultants, Inc. a consulting firm and President of American Rehab of South Florida, Inc. (CORF). Leyva brings over 10 years of experience in the healthcare industry.  She is currently working towards her Risk Management license at Florida International University.