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Medicare Home Health Qualifications

What is Medicare Home Health? How much do I have to pay?
Who is eligible for Home Health How long will they help me?
How do I get Home Health? What types of home care are there?
Home Health Compare

Many health care treatments that used to be done only in a hospital can now be done in your home. Health care given in the home is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility. If you are eligible, Medicare pays for you to get certain health care services in your home. This is known as the Medicare home health benefit.

If you get your Medicare benefits through a Medicare HealthPlan, other than the Original Medicare Plan, check your plan’s membership materials and call the plan for details about how the plan provides your Medicare-covered home health benefits.

What are Medicare's Home Health Services?

Medicare beneficiaries can receive health care services in the home. Home health services can include:

  • Skilled nursing (including planning and monitoring your care)
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Home Health Aides (Including assistance with care such as bathing, dressing, grooming, changing bed linens, feeding, toileting, transfers, ambulation, simple dressing changes, range of motion exercises and other routine therapy and, in some instance, personal laundry and light meal preparation.
  • Medical Social Services (such as social workers)
  • Medical Supplies (including durable medical equipment)

Who is Eligible to Receive Home Health Services?

If you have Medicare, you can use your home health benefits if you meet all the following conditions:

1. Your doctor must decide that you need medical care at home, and make a plan for this care.

2. You must need one or more of the following:

  • Intermittent skilled nursing care
  • Physical therapy
  • Speech-language pathology services
  • Continued occupational therapy
Skilled nursing includes non only "hands-on" treatment, but observation of your changing condition. There is no requirement that your condition must improve.

Intermittent can mean skilled nursing case as infrequently as once every 62 days. Some people can need a nurse less than once every 62 days and still receive home health aide services, as long As they have a regular and predictable need for a nurse. For instance, you may need a nurse to assist you in administering B12 injections once every 90 days.

3. The home health agency caring for you must be approved by the Medicare Program (Medicare-certified).

4. You must be homebound or normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to attend religious services. You can still get home health care if you attend adult day care.

Eligibility is also based on the amount of services you need.

If you meet the conditions above, Medicare pays for your covered home health services for as long as you are eligible and your doctor says you need them. However, the skilled nursing care and home health aide services are only covered on a part-time or "intermittent" basis. This means there are limits on the number of hours per day or days per week that you can get skilled nursing or home health aide services.

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How Do I Get Home Health Services?

If your think you may be eligible for home health benefits, ask your physician to develop a plan of care for you. If you are hospitalized, you may aks the hospital discharge planner to set up these services for you. You can also ask a nurse from a home health provider to evaluate your need for home care services and to develop a plan of care. In a managed care plan, you must get prior approval for an evaluation.

The nurse will visit your home, develop a plan of care, and submit her plan to your physician for final approval. You must get home health care services from a provider that is Medicare-certified or selected by your managed care plan.*

Even if you have a chronic, terminal, and/or degenerative condition, home health coverage may be available to you. For example, you may need skilled nursing or therapy services to prevent or slow further deterioration or to preserve current capabilities.

*Contact Vienna Medical with your prescription and we can help in finding you a home health company in Volusia County. 

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How Much Will I have to Pay for Home Health Services?

Unlike other Medicare services, Medicare home health benefits require no co-payment or deductible amounts. There is an exception for durable medical equipment where you musty pay a 20% co-payment.

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How Long Am I Entitled to Home Health Services?

You can receive home health services for as long as you continue to meet the coverage criteria. You can receive a combination of home health services for up to seven days per week and up to 28 hours per week as long as the need for these services is documented by the home health provider. In addition, you can receive up to 35 hours per week of daily services as long as the need for these services is for a finite period of time. A terminal condition, for example, might allow you to qualify for these increased hours.

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What Types of Home Health Services Are Available?

Some examples of home health services covered by Medicare are:

You have hypertension and suffer from dizziness and weakness. Your doctor is concerned that your blood pressure is too low and has stopped your hypertension medication. Home health coverage will allow a nurse to observe and monitor your blood pressure until it remains stable and in a safe range.

You were recently diagnosed as a diabetic. You need a skilled nurse to teach you to self inject, to manage your insulin, to understand the signs and symptoms of insulin shock, and how to respond to emergencies. The teaching services would be covered as a home health benefit.

You recently broke a leg bone which has not healed and is unstable.You need regular exercise to maintain function until the bone heals. A physical therapist visits to make sure that your leg is properly aligned during your maintenance exercises. Medicare will cover the therapist's services.

You have Alzheimer's diseaseand get confused about whether you took your medications and how much you are supposed to take. Medicare will cover a nurse to come to your home to assess your medical symptoms for medication compliance , and to ensure that your overall care plan is adequate.

You have multiple sclerosisand require regular exercise so that your condition does not deteriorate. Medicare will cover a physical therapist to come to your home and ensure that your exercise program remains appropriate.

Although you are homebound, your managed care plan requires you to obtain your physical therapy at their outpatient facility. You also require a nurse to come to your home to change your catheter once a month and the daily assistance of a home health aide with bathing and dressing. Because you leave home for a medical service, the managed care plan will cover the nursing and home health aide visits in your home.
These are just a few examples of the types of services you can get if you are determined eligible for Medicare's home health benefit. Remember, Medicare will also cover home health aides or social workers if Medicare is covering a nurse or therapist.

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