Medicare Home Health Care Benefit Explained

As Florida elder care lawyers, our goal is to help our clients take advantage of every program available in a long-term care context. Many of our clients want to stay at home for as long as possible, but need help. Usually, our clients ask us for help protecting their assets to qualify for the Florida Medicaid Waiver's valuable home health care program. Most of my clients are already on Medicare and its important to note that Medicare has a home health benefit as well (albeit tougher to get). Medicare and Medicaid are inherently difficult programs to navigate, which is where our elder law firm can help. The purpose of this article is to further explain the:

Home Health Care Benefits Available Through Medicare

In order to be eligible for Medicare home health services, a patient must have Medicare Part A, Part B, and be confined to the home (homebound), in need of skilled services, under the care of a doctor (MD, DO, Physician’s assistant, nurse practitioner, or podiatrist who is enrolled as a Medicare provider) who establishes a care plan after face-to-face medical evaluation and regularly reviews a 60 day plan of home care.   

Homebound does not mean “bed bound” or never able to leave the house. Instead, Medicare defines “confined to the home” (homebound) as:  

• Because of illness or injury, in need of assisted devises such as canes, crutches, walkers, or wheelchairs or require other special assistance to leave their place of residence; or
• Have a condition that makes leaving the house is not medically recommended (e.g. can physically leave, but has dementia and is likely to get lost); and
• There must be a normal inability to leave the house without considerable additional effort. 

Floridians who are homebound are allowed to leave their home if such incidents are: infrequent, of short duration (e.g. going to church, getting a haircut, grandchild’s wedding, etc...), or for the need to receive medical or psychiatric health care treatment, or to go to an adult-daycare center. 

Skilled services are defined as: inherently complex enough that should be performed by or under the supervision of a qualified professional (to treat illness, injury, maintain or prevent further deterioration, or improve their condition). Importantly: restoration potential is NOT the deciding factor for deciding whether Medicare coverage should be made available. “…even if full recover is not possible, a patient may need skilled services to prevent further deterioration or preserve currently capabilities.” 42 CFR 409.32. 

Medicare Home Health Care Services

Sec 1861(m) of the Social Security Act, here are the following Medicare covered home health care services: 

1. Skilled Nursing services at home on a part-time or intermittent basis

2. Home health aides on a part time or intermittent basis (intermittent basis means: less than seven days a week or less 8 hours a day for a period of 21 days or less…with extensions in exceptional circumstances). Home health care is ONLY provided if a skilled service is certified to be needed FIRST – up to 28 hours per week…but for less than 8 hours per day. Exceptional circumstances can increase Medicare's home care hours to 35 hours per week.

Medicare home care providers can provide hands-on personal care: bathing, dressing, grooming, caring for hair, nails, oral hygiene to facilitate treatment or prevent deterioration, changing bedlinen of incontinent patient, feeding assistance, routine catheter and colostomy care.

These items do not required skilled nursing care, but skilled care or skilled therapy is needed in order to qualify for these limited non-skilled services. This is the primary reason why Medicare's home health benefits are more difficult to qualify for as compared to the Medicaid Waiver home care benefit (which does not have the skilled care prerequisite).

• Medicare home health care is always available so long as the skilled care is needed as well and other threshold criteria are met (e.g. homebound, care plan, etc…). Plan re-certifications can be met
• Far too often, Medicare home-health agencies only provide 1-3 hours per week, usually for bathing only, and claiming that services are not available if not expected to result in an improvement.
• There is no prior hospital stay, or 100 day limit, for Medicare home health care eligibility.

3. Physical Therapy

4. Occupational Therapy

5. Speech Therapy

6. Social Services

7. Routine and Non-Routine Medical Supplies (e.g. catheters, catheter-care supplies, colostomy bags and care supplies).

8. Durable Medical Equipment needed for the treatment of illness, injury or condition at home or assisted living facility (e.g. hospital beds, wheelchairs, dialysis equipment, respirators, crutches, walkers, CPAP devices, oxygen equipment, blood sugar monitors and test strips, infusion pumps, speech generating devise)

9. Osteoporosis injectable drugs.  

Home Health Care Benefits that Medicare Does NOT Cover:

1. Drugs (covered by Part D)

2. Housekeeping services

3. Transportation

4. General help with activities of daily living unless skilled nursing care is needed first to maintain function or prevent/slow a decline.

Additional Medicare Resources

Thank you to the Center for Medicare Advocacy for your valuable information and advocacy efforts.

For Medicare Counseling (in every state): https://www.shiptacenter.org/

To Report Suspected Medicare Errors or Fraud: https://www.smpresource.org

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