If you have Medicare or other qualifying insurance or prefer to pay privately, you can use your home health benefits if you meet all the following conditions:
1. You must be under the care of a doctor.
2. You must need, and a doctor must certify that you need one or more of the following:
- Intermittent skilled nursing care
- Physical therapy
- Speech-language pathology services
- Occupational therapy
3. You must be homebound, and a doctor must certify that you're homebound.
What does homebound mean?
- Leaving your home isn't recommended because of your condition.
- Your condition keeps your from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person).
- Leaving home takes a considerable and taxing effort.
A person may leave home for medical treatment or short, infrequent absences for non-medical reasons such as attending religious services. You can still get home health care if you attend adult day care, but you would get the home care services in your home.
What medicare covers
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.
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 you 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, and 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.
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.
- 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.
- Medical supplies. Supplies, like wound dressings, are covered when they are ordered as part of your care.
What isn't covered
Below are some examples of what Medicare doesn't pay for:
- 24-hour-a-day care at home.
- Meals delivered to your home.
- 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.
- Personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need.
Talk to your doctor or the home health agency if you have questions about whether certain services are covered.
You can also call 1-800-MEDICARE (1-800-633-4227)
TTY users should call 1-877-486-2048
Note: If you have a Medigap (Medicare Supplement Insurance) policy or other health insurance coverage, be sure to tell your doctor or other health care provider so your bills get paid correctly.
What you have to pay
You may be billed for the following:
- Medical services and supplies that Medicare doesn't pay for when you agree to pay out of pocket for them. The home health agency should give you a notice called the Home Health Advance Beneficiary Notice (HHABN) before giving you services and supplies that Medicare doesn't cover.
- 20% of the Medicare-approved amount for Medicare-covered medical equipment such as wheelchairs, walkers, and oxygen equipment.
Getting Home Health Care
Usually, once your doctor refers you for home health services, staff from Grace Reliant will come to your home to talk to you about your needs and ask you some questions about your health. Grace Reliant will also talk to your doctor about your care and keep your doctor updated about your progress. Doctor's orders are need to start care.
Your plan of care
Grace Reliant will work with you and your doctor to develop your plan of care. A plan of care lists what kind of services and care you should get for your health problem. You have the right to be involved in any decisions about your plan plan.
Your plan of care includes the following:
- What services you need
- Which health care professionals should give these services
- How often you will need the services
- The medical equipment you need
- What results your doctor expects from your treatment