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Vol. 13, Issue 16  • August 11, 2014

When does Medicare pay for home health care?

Dear Marci,My doctor said that I might benefit from home health care services due to my illness. When does Medicare pay for home health care services?

- Anne (Yakima, WA)

Dear Anne,

Home health care is care provided to you at home in order to treat an illness or injury. Medicare does pay for home health care services, but only under specific circumstances. Medicare will pay for home health care only if you meet all four of the following requirements:

  1. You are homebound, which means you need the help of a person or equipment to leave your home, and it is extremely difficult to do so;
  2. You require skilled care on an intermittent basis, such as skilled nursing care or skilled therapy services that must be administered by a licensed nurse or therapist;
  3. Your doctor has signed a home health certification stating that you qualify for Medicare home health care because you are homebound and need intermittent skilled care. The certification also must state that you have a plan of care that is regularly reviewed by your doctor. As part of this plan of care, you must have a face-to-face visit with your doctor related to the main reason you need home care within 90 days of starting home health care or within 30 days after the start date; and
  4. You receive your home health care services from a Medicare-certified home health agency (HHA).

If you meet all four of these requirements, Medicare should pay for the skilled care that you receive in your home. The Medicare home health care benefit will cover skilled nursing care, which are services and care that can only be performed safely and effectively by a licensed nurse, such as injections or wound care. The home health benefit will also cover skilled therapy services like physical, speech, or occupational therapy. Note that if you need only occupational therapy, you will not qualify for the Medicare home health care benefit. However, if you qualify for Medicare home health care on another basis, you can also get occupational therapy. Medical social services, and certain medical supplies provided by the Medicare-certified home health agency, such as wound dressings and catheters that are needed for your care, are also covered under Medicare’s home health care benefit.

You will continue to receive home health care for as long as you qualify for the benefit. However, your doctor will need to approve a new plan of care every 60 days for the benefit to continue. Note that you do not need to meet face-to-face with your doctor each time you renew your plan of care, but you must do so when first developing your plan of care.

If you have Original Medicare, the traditional Medicare program administered directly through the federal government, Medicare pays the full cost of home health care. Medicare Advantage plans must follow the same rules as Original Medicare for providing you care, but may have different costs and restrictions for home health care. Contact your plan directly to learn more about your plan’s coverage of home health care and its network of home health care providers.


Health Tip
A recent study published in The Lancet found that acetaminophen may not be helpful in treating lower back pain. Researchers studied a group of 1,643 people whose average age is 45 years old to see whether taking acetaminophen relieved their back pain symptoms. One group of participants received only acetaminophen, one group received a mix of acetaminophen and placebo pills, and one group received only placebo pills.Over three months, the researchers found no significant differences between the three groups in pain, functioning, recovery time, sleep, or quality of life. About 75 percent of the participants were satisfied with their treatment course, whether they received acetaminophen or placebos. The study provides interesting new information regarding back pain treatment. However, researchers state that someone can continue to take acetaminophen if it helps with back pain symptoms.

Click here to read the New York Times article that summarizes the study. Click here to read the entire study.

Need to Know
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Dear Marci is a biweekly e-newsletter designed to keep you — people with Medicare, social workers, health care providers and other professionals — in the loop about health care benefits, rights and options for older Americans and people with disabilities.

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