When it comes to home health care, one of the most frequently asked questions is: “Is this covered by Medicare or Medicaid?” This is understandable, considering that home care is an umbrella term that can refer to a variety of health and social services provided at home to people with who require specialized care or assistance with day-to-day tasks.
It is important to understand the distinctions because not everything under the “home care” umbrella is covered under Medicare. It is crucial that home health care providers be aware of which services are and are not covered in order to best help their patients and to minimize their risk of claims.
Understanding Coverage Conditions
Medicare will provide payment for home health care if these four conditions are met:
- The patient is considered “homebound,” which means the patient must require the help of special equipment or another person to leave his or her home or their doctor believes that leaving the home would be harmful to their health.
- The patient requires “skilled care,” including skilled nursing care intermittently (ranging from once every 60 days to once a day for several weeks), or skilled therapy services (such as physical or speech therapy).
- The patient’s physician signs a home health certification stating that they qualify for Medicare home health care because they are homebound and require intermittent skilled care. The certification is often combined with a plan of care (which is also required).
- The patient receives his or her care from a Medicare-certified home health care agency.
If these conditions are met, the patient in question can request that Medicare cover their home health care services. That said, there are still specific types of care involved that Medicare will cover, and others that they will not.
What Medicare Will Cover, and What it Won’t
Types of home care covered by Medicare include:
- Skilled nursing services and home health care services, for no more than eight hours a day and 28 hours per week (though Medicare will cover up to 35 hours in special cases)
- Skilled therapy services, including physical, speech, and occupational therapy
- Medical social services (such as counseling)
- Certain medical supplies
- Durable medical equipment, with a 20 percent coinsurance fee for the patient
On the other hand, Medicare does not coverthese varieties of home health care (though the Medicare hospice benefit may cover some of these services for patients at the end of life):
- Prescription drugs (Medicare drug coverage will only be provided in a Medicare Part D plan)
- 24-hour home care
- Meal delivery
- Homemaking or custodial services, unless custodial care is included in the skilled nursing or skilled therapy services provided by a home health aide or another attendant
Upcoming Industry Changes
Home health care agencies must keep in mind that some of the above conditions may be subject to change. On January 13, 2018, the Conditions of Participation (CoPs) took effect, providing a new set of regulations for home health care agencies on the requirements for participating in Medicare and Medicaid programs.
At this time, providers are still awaiting the Centers for Medicare & Medicaid Services (CMS) to release the final interpretive guidelines (IGs), which will provide more details on select regulations. A draft version was released in 2017 in order to provide clarification, as many providers were looking for more information on the new regulations for personnel and the patient bill of rates, among other things. As a concession, CMS has agreed to hold off on implementing civil monetary penalties (CMPs) until January 13, 2019, once the CoPs have entered their second year in effect.
About Caitlin Morgan
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