Understanding Medicare's Home Health Benefit
Medicare's home visit coverage is specifically tied to its home health benefit, available under both Part A (Hospital Insurance) and Part B (Medical Insurance). This is not a general errand service or a program for everyday custodial care like cleaning and meal prep. Instead, it is a targeted medical benefit for those who are homebound and require skilled care.
The 'Homebound' Requirement
For a senior to qualify for Medicare home visits, they must be certified by a doctor as homebound. This does not mean they can never leave their house. The criteria for being homebound include:
- Significant effort: Leaving the home takes considerable and taxing effort.
- Assistance needed: The individual needs help from another person or a mobility aid like a cane, walker, or wheelchair to leave.
- Medical advisement: A doctor has advised against leaving the home due to the individual's medical condition.
What does 'intermittent' mean?
Home health services must be provided on a part-time or intermittent basis. For most beneficiaries, this means they can receive skilled nursing care and home health aide services for up to 8 hours a day, with a maximum of 28 hours per week. In certain cases where a doctor deems it necessary, this can be temporarily increased to a maximum of 35 hours per week. This distinguishes home health from round-the-clock or long-term custodial care, which Medicare generally does not cover.
Services Covered During a Home Visit
When a senior meets the eligibility criteria, Medicare can cover a range of services provided by a Medicare-certified home health agency. These include:
- Skilled Nursing Care: Services like wound care, injections, catheter changes, and monitoring of a serious illness.
- Therapy Services: Physical, occupational, and speech-language therapy to help a person regain or maintain function.
- Medical Social Services: Counseling and assistance with social and emotional concerns related to the illness.
- Home Health Aide Services: Assistance with personal care tasks like bathing, dressing, and using the bathroom. Crucially, these services are only covered if the senior is also receiving skilled nursing or therapy services.
- Medical Supplies and Durable Medical Equipment (DME): Covered supplies include wound dressings and catheters. Durable Medical Equipment like wheelchairs and walkers are also covered, typically at 80% of the Medicare-approved amount.
Original Medicare vs. Medicare Advantage Home Visits
Both Original Medicare and Medicare Advantage plans cover the home health benefit, but there are some key differences in how they operate.
Comparison Table: Original Medicare vs. Medicare Advantage Home Visits
| Feature | Original Medicare | Medicare Advantage (Part C) |
|---|---|---|
| Eligibility | Requires being homebound and needing intermittent skilled care, certified by a doctor. | Must meet the same homebound and intermittent skilled care requirements. |
| Provider Choice | Allows the beneficiary to choose any Medicare-certified home health agency in their area. | Plan may require the use of agencies within its network for coverage. |
| Annual Wellness Visits | Covers an annual wellness visit with a primary care provider in a clinical setting. | May offer supplemental in-home health assessments by a licensed clinician to identify health risks, often called a 'Healthy Home Visit.' This is in addition to the annual wellness visit. |
| Costs | Pays 100% for approved home health services. The Part B deductible applies to Durable Medical Equipment. | Typically pays 100% for approved home health services, but copays or cost-sharing may apply depending on the plan. |
| Care Coordination | Offers care coordination through Accountable Care Organizations (ACOs) or for Chronic Care Management (CCM) for those with multiple chronic conditions. | Includes robust care coordination as a central component of managed care, aiming to improve health outcomes and reduce costs. |
Physician Home Visits
Beyond the home health benefit provided by a home health agency, individual physicians and healthcare providers may also conduct home visits. Medicare Part B covers these visits when they are considered medically necessary, such as for a patient whose condition makes an office visit difficult. Some modern primary care practices now specialize in house calls, providing comprehensive care to homebound patients. The American Academy of Family Physicians, for example, has published information on billing and documentation for these types of visits.
How to Initiate a Medicare Home Visit
To arrange for Medicare-covered home visits for a senior, follow these steps:
- Consult with the Doctor: The senior’s doctor or other approved provider must certify the need for home health services and confirm the patient is homebound. They will also create a plan of care.
- Select a Certified Agency: The doctor can provide a list of Medicare-certified home health agencies in the area. Beneficiaries with Original Medicare can choose any certified agency, while those with a Medicare Advantage plan may need to use an in-network provider.
- Receive Your Visits: Once a plan is established and the agency is selected, visits will be scheduled according to the prescribed frequency and type of care needed.
What Medicare Does Not Cover in Home Visits
It is important to be aware of the limitations of Medicare's home visit coverage to avoid unexpected costs. Medicare does not cover:
- 24-hour-a-day care at home.
- Homemaker services like shopping, cleaning, and meal preparation (unless required during a covered skilled nursing visit).
- Custodial care (non-skilled personal care) when it is the only care needed.
In these situations, other options such as Medicaid, long-term care insurance, or private pay might be necessary.
The Role of Care Coordination
For seniors with multiple chronic conditions, care coordination is a vital component of successful home-based care. This can help manage all aspects of a senior's health, from scheduling appointments to ensuring all providers are on the same page. In Original Medicare, this is often handled through Accountable Care Organizations (ACOs), while Medicare Advantage plans typically include care coordination as a core feature.
Conclusion
Medicare can provide crucial home visits for seniors, but only when specific criteria are met. The benefit is designed for those who are homebound and require intermittent skilled medical care, not for general long-term support. By understanding the distinction between skilled home health, physician house calls, and un-covered custodial care, seniors and their families can better navigate their options. Always confirm coverage and requirements with a doctor and the home health agency to ensure the right care is provided without financial surprises. For more detailed information on covered services, visit the official Medicare website.
