©1995 by Sharon Emerson
Medicare pays for many important home health care needs. In order for Medicare to cover home care services, all of the following must be true:
- You must need "skilled intermittent" nursing care, or speech, occupational, or physical therapy. More about this later.
- You must be "homebound", which means you can't leave home unassisted and you can leave your home only with "considerable and taxing effort". You may leave home only for medical treatment or short, infrequent non-medical reasons like going to church or to get a haircut. If you can go shopping or out to a restaurant you are not "homebound".
- Your physician must order homecare and approve and sign your Plan of Treatment.
- The Home Health Agency must be medicare-certified.
If all of the above are true, Medicare also covers services by Home Health Aides and Medical Social Workers. These services must also be ordered by the physician.
What is a Plan of Treatment?
A Plan of Treatment is a piece of paper signed by your physician that has:
- Basic information such as your name, address, and
- The medical diagnoses you have that affect your current health status
- A list of your medications
- A list of the medical problems that the Home Health Agency plans to help you with
- A list of orders saying what kinds of health professionals are going to be helping you, what they are going to do to help you, and how often they plan to come
- A list of goals for your health that the agency is planning to accomplish
Will my needs be covered by Medicare?
The Medicare Home Health Care benefit is wonderful and enables many people to stay in their homes. However, Medicare limits the amount of Skilled Nursing and Home Health Aide services you can receive. These services together must be delivered less than 7 days a week, less than 8 hours per day, and less than 28 hours a week. Most regular health insurance companies follow the Medicare guidelines for what type of homecare is covered.
But what if you need more than what Medicare covers? What if you need help with laundry, housekeeping and cooking? What if you still need help with bathing, but no longer need therapists or skilled nursing? That's where Private Duty agencies such as Island Home Nursing come in. Their services are paid in full by the client or, depending on the policy, by Long Term Care Insurance policies. Most states also have Medicaid policies that cover this type of care. Here are some differences between the two:
"Intermittent" versus Private Duty Care
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Intermittent |
Private Duty
Like Island Home Nursing |
| Who pays for the care? |
Medicare and most regular insurance. |
Paid by the client, Medicaid, or by Long Term Care Insurance. |
| Patient must need "skilled" care and must be "homebound". |
YES |
If client paid, NO, otherwise as required by Medicaid or Long Term Care insurance policy. |
| Care must be ordered by physician. |
YES |
If client paid, NO, otherwise as required by Medicaid or Long Term Care insurance policy. |
| Agency must be Medicare-certified. |
YES |
If client paid, NO, otherwise as required by Medicaid or Long Term Care insurance policy. |
| A Plan of Care signed by the doctor is required. |
YES |
If client paid, NO, otherwise as required by Medicaid or Long Term Care insurance policy. |
| How often are the visits? |
As often as needed to accomplish the goals on the Plan of Treatment, usually 2-3X/week, occasionally daily, and (rarely) 2x/day. |
If client paid, as often as you want and can afford. Otherwise, as authorized by Medicaid or Long Term Care policy. |
| How long are the visits? |
As long as medically necessary, usually less than an hour. |
If client paid, as long as you want, with a usual 2 or 3 hour minimum. Otherwise, as authorized. |
| How long do the visits continue? |
Until the goals of treatment are met, provided the client is still homebound. |
If client paid, as long as you want, with a usual 2 or 3 hour minimum. Otherwise, as authorized. |
| What is done during the visit? |
Personal care tasks listed in the Plan of Care, such as bathing and dressing. No homemaker tasks such as shopping, cleaning, and laundry. |
If client paid, anything that is both legal and allowed by agency policy for the caregiver. Otherwise, as authorized. |
This is too complicated.
Is there another way to find out if Medicare will pay for the help I need?
The best way to find out whether Medicare will cover your home health needs is to request an evaluation from a Medicare-certified Home Health Agency in your area. Either call the agency directly or ask your physician to refer you to one. Don't get your information from a non-certified agency-- the rules are complicated and change often.
For more information:
For more information, view the Medicare pamphlet, Medicare and Home Health Care.
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