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Medicare Home Health Care Rules
Medicare pays for professional home health care services for eligible senior citizens, and younger disabled individuals, if they meet fairly strict criteria. Medicare covers services in the home including nursing and physical, occupational and speech therapy services. It will also covers social work and home health aide services if nursing or therapy service is present. Medicare does not cover companions or homemakers.
Our Transitional Care Department, 203.458.4275, (toll free) 1.866.862.0888 or email, is pleased to answer your questions. At the bottom of this page is a sheet with the exact Medicare Homebound regulations.
Medicare May Cover:
- Skilled Nursing (medical surgical or psychiatric).
- Home Health Aides for personal care help only while skilled services are needed.
- Physical, occupational or speech therapies.
- Medical social work.
Medicare May Pay for Home Health Care if:
1. Home health care is needed to appropriately treat the medical condition, and is considered medically necessary.
2. The patient is “homebound.” [see definition below]
3. (NEW FOR 2011) A "face to face encounter" (medical visit) is required for traditional Medicare patients within the 90 days prior to, or the 30 days following, the start of home care services. Documentation of the "face to face encounter" must be done under the physician's signature, even if the visit was done by an APRN or PA. If the visit was done by an APRN or PA, that clinician must inform the physician of his/her findings for the purpose of documentation. For more information about the 2011 changes to Medicare Home Care Regulations, click here.
4. There is a Plan of Care approved and signed by the patient’s physician. 5. Skilled services—such as nursing, physical therapy or speech therapy—are required and cannot be performed by a nonmedical person.
6. Required care is intermittent or part-time (usually less than 35 hours a week).
7. The patient is expected to improve—goals are set and progress is seen.
8. The patient’s home care agency is approved by Medicare.
9. Home care services are delivered in the patient’s primary place of residence.
Medicare will pay for home health aides to help with personal care only as long as you need a nurse, or physical or speech therapist.
When is a patient considered “homebound”?
Homebound means that leaving home is a major, taxing effort for the patient. For example, when medical conditions or symptoms like dyspnea, weakness, frailty, confusion, pain, use of crutches, a wheelchair or the need for assistance from another person make leaving home difficult.
A homebound patient may be able to leave the home only for infrequent or short trips. For example, medical appointments, short walks, attendance at Adult Day Care or religious services, or occasional family events are considered short trips.
However, patients who drive themselves or leave home on a regular basis to attend bingo at their local senior center or other recreational regular activities are not considered homebound. A patient may be considered temporarily homebound while recovering from surgery, serious illness or trauma.
Medicare Will Not Pay for Home Care if:
- The patient’s condition is “chronic and stable.”
- The patient is not likely to improve with home care.
- The patient is not homebound.
- A "face to face encounter" (medical visit) documentation for traditional Medicare patients is not submitted and signed by a physician within the 90 days prior to, or the 30 days following, the start of home care services.
- Home care is not medically necessary to treat the patient’s medical condition.
- Only assistance with ADLs is needed.
1. Does “homebound” mean that a patient is never able to leave the house?
NO, homebound means that a patient can only leave home with help or with “taxing effort.” Short trips for medical care, for a walk or to the hairdresser are allowed. Adult day care is allowed if there is a medical component.
2. Can Medicare patients receive home care on a daily basis until benefits are exhausted?
Under most circumstances, there is no limit on the duration of home health care services under the Medicare benefit as long as they are medically necessary. However, Medicare specifies that care must be either intermittent or part-time. Part-time is defined as a maximum of 28 hours per week (can be increased to 35 hours if the patient’s condition warrants.) and less than 8 hours per day. Care can be delivered up to 7 days a week for up to 21 consecutive days.
3. Is the attending physician responsible for certifying that home care is medically necessary?
YES, the supervising physician is responsible for certifying medical necessity for home care services. Elements of medical necessity include: severity of symptoms, changes in symptoms, home environment, home support systems, comorbidities and patient and family capabilities for care. The physician must recertify the care plan every 60 days.
4. Are there new regulations for the Home Care Benefit for traditional Medicare recipients?
YES. Beginning January 1, 2011, in an attempt to reduce fraud and increase physician involvement in ordering home care services, Medicare will institute a new rule that home health care agencies must follow as a condition of payment. Traditional Medicare (not Medicare Advantage plan) members will be required to have a "face to face encounter" (medical visit) with a physician, nurse practitioner or physician assistant within the 90 days prior to the start of home care services or the 30 days following. There are also new rules about documenting the "face to face encounter." Click here for more information about the new 2011 Medicare Home Care regulations.
VNA Community Healthcare is Medicare approved and certified.
For comprehensive information on Medicare, please visit: www.Medicare.gov or contact our Transitional Care Department directly, 203.458.4275, (toll free) 1.866.862.0888 or email.
Medicare Homebound regulations
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