Nursing home

When is Home Care Covered by Medicare?

When certain criteria are met, home care covered by Medicare is available.  There is no legal limit on the length of time for which home health coverage is available. Further, Medicare covers home health services in full, with no required deductible or co-payments. Home Health Care claims are covered by Medicare if certain criteria are met:

  1. The patient is “homebound.” (42 CFR 409.42). A patient is considered to be “homebound”  if leaving home requires a considerable and taxing effort which may be shown by the patient needing personal assistance, or the help of a wheelchair or crutches, etc.  Occasional but infrequent “walks around the block” are allowable.  CMS Policy Manual 100-02, Chapter 7, §30.1.1.  A Medicare beneficiary does not need to be bedbound to be eligible for Medicare coverage of home health care. Furthermore, being homebound does not mean that the beneficiary never leaves home.Beneficiaries can leave home as frequently as needed to attend: religious services; adult day care where they are participating in therapeutic, psychosocial, or medical treatments; or medical appointments. Medicare beneficiaries are considered homebound if leaving home for social reasons or errands is difficult and thus happens infrequently or only for short periods of time. Absences from the home for special occasions such as family celebrations or occasional outings should not disqualify Medicare beneficiaries from Medicare home health care coverage (Medicareadvocacy.org).
  2. A physician has signed or will sign a plan of care for home health services.
  3. The patient was seen by the ordering physician (or APRN or PA) and the physician certifies the patient is homebound and needs skilled care.
  4. The patient needs or will need physical or speech therapy, or intermittent skilled nursing (from once a day for periods of 21 days at a time if there is a predictable end to the need for daily nursing care, to once every 60 days) CMS Policy Manual 100-02, Chapter 7, §40.1.3.
  5. The home health care is provided by, or under arrangement with, a Medicare-certified provider2 CFR §409.42(e).

If the criteria above, the beneficiary is eligible for Medicare coverage for home health services. Home health services include:

  • Part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse;
  • Physical, occupational, or speech therapy;
  • Medical social services under the direction of a physician and;
  • To the extent permitted in regulations, part-time or intermittent services of a home health aide.

Custodial care is not covered.

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