Medicare Criteria for Home Health

Once you qualify to receive Medicare, depending on your condition, the national insurance provider might also pay for home health care services you receive. Hospice and home care services obtained through a private licensed home care agency are types of services Medicare covers. Skilled caregivers (for example, registered nurses) provide hygiene, physical therapy, meal preparation and light housekeeping support to eligible adults and youth.

Physician Approval

• You must currently receive regular care from a physician to qualify for home health care. The physician that provides your care must verify that you require intermittent care from a licensed nurse or that you require physical therapy, speech-language pathology support or occupational therapy before Medicare will pay for the services.

Living Arrangement

• If your physician certifies that you are unable to leave your home (that you are homebound) due to your medical condition, you might qualify for home health care. Should you need to use a wheelchair, walker or other equipment or require the help of an aide to travel away from home, Medicare considers you homebound. Other than leaving your home to go to doctor visits, you are only allowed to make short, nonmedical related trips. For example, you are permitted to attend church or visit with family. Frequent trips away from home could disqualify you for home health care.

Types of Care

• Medicare will pay for you to receive support from a registered nurse (RN) or a licensed practical nurse (LPN). Care provided by an LPN is supervised by an RN. Under this care prescription drugs are administered via an IV, a shot or orally. Counseling, equipment and supplies related to your treatment, and training on how to administer your medications (by yourself or a friend or family member), are also provided. Generally, Medicare pays up to 80 percent of the cost of medical equipment (for instance, a walker, a wheelchair). The expectation that your condition will improve by a specific time must exist.

Length of Service

• Part-time, intermittent care is the maximum home health care provided under Medicare. Care is provided for less than seven days a week and fewer than eight hours a day. Total length of care is 21 days. In some cases, you could receive an extension on the care; however, your physician must provide a clear end date for the at-home services to Medicare. If you have a medical condition that requires long-term, in-home care you must pay for those services out of pocket using services offered through a private at-home care agency.

Home Care Agencies

• Home care agencies that you use require Medicare approval. Medicare also approves the dollar amount of the care that they will pay for. Ask agencies that you work with to give you a Home Health Advance Beneficiary Notice (HHABN) that lists services Medicare does not cover before they start providing you with care. This way you will know the expenses you are responsible for paying out of your own pocket.