If you have Medicare, you can use your home health care benefits if you meet all the following conditions.

1. Your doctor must decide that you need medical care at home, and make a plan for your care at home.
2. You must need at least one of the following: intermittent skilled nursing care, or physical therapy, or speech-language therapy, or continue to need occupational therapy.
3. The home health agency caring for you must be approved by the Medicare program (Medicare-certified).
4. You must be homebound, or normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to the barber or to attend religious service. A need for adult day care doesnt keep you from getting home health care.

Eligibility is also based on the amount of services you need.

Medicare covers your home health services for as long as you are eligible and your doctor says you need these services. However, the skilled nursing care and home health aide services are only covered on a part-time or “intermittent” basis. This means there are limits on the number of hours per day and days per week that you can get skilled nursing or home health aide services. Therapy services dont have to be part-time or “intermittent”. To decide whether or not you are eligible for home health care, Medicare defines part time or intermittent as skilled nursing care that is needed or given on fewer than seven days each week or less than eight hours each day over a period of 21 days (or less) with some exceptions in special circumstances. See example in the next section.

Hour and day limits may be extended in exceptional circumstances when your doctor can predict when your need for care will end. Once you are getting home health care, Medicare defines part-time or intermittent as skilled nursing or home health aide services combined to total less than 8 hours per day and 28 or fewer hours each week. Based on your need for care, on a case-by-case basis, the weekly total may be increased to up to 35 hours. This definition helps Medicare make decisions about your coverage.

If you meet all four of the conditions for home health care, (listed above) Medicare will cover

• skilled nursing care on a part-time or intermittent basis. Skilled nursing care includes services and care that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).
• home health aide services on a part-time or intermittent basis. A home health aide doesnt have a nursing license. The aide provides services that give additional support to the nurse. These services include help with personal care such as bathing, using the bathroom, or dressing. These types of services dont need the skills of a licensed nurse. Medicare doesnt cover home health aide services unless you are also getting skilled care such as nursing care or other therapy. The home health aide services must be part of the home care for your illness or injury.
• physical therapy, speech-language therapy, and occupational therapy for as long as your doctor says you need it.
  1. Physical therapy: including exercise to regain movement and strength in a body area, and training on how to use special equipment or do daily activities, like how to get in and out of a wheelchair or bathtub.
  2. Speech-language therapy (pathology services): including exercise to regain and strengthen speech skills.
  3. Occupational therapy: to help you become able to do usual daily activities by yourself. You might learn new ways to eat, put on clothes, comb your hair, and new ways to do other usual daily activities. You may continue to receive occupational therapy even if you no longer need other skilled care if ordered by your doctor.
• medical social services to help you with social and emotional concerns related to your illness. This might include counseling or help in finding resources in your community.
• certain medical supplies like wound dressings, but not prescription drugs or biologicals.
• durable medical equipment such as a wheelchair or walker.
• FDA (Food and Drug Administration) approved injectable osteoporosis drugs in certain circumstances.

Medicare doesnt pay for

• 24-hour-a-day care at home;
• prescription drugs;
• meals delivered to your home;
• homemaker services like shopping, cleaning, and laundry; and
• personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need.

Although Medicare doesnt cover prescription drugs as part of home health care, a recent law added new prescription drug benefits to the Medicare program as a whole. Under the new law, all people with Medicare will be able to enroll in plans that cover prescription drugs. In 2004, Medicare-approved drug discount cards were made available to help you save on perscription drugs. In 2006, a prescription drug benefit will be added to Medicare that pays some, but not all, of your prescription drug costs.

The Original Medicare Plan pays the full Medicare-approved amount (cost) of all covered home health services. The home health agency sends bills to Medicare. Before your care begins, the home health agency must tell you how much of your bill Medicare will pay. The agency must also tell you if any items or services they give you are not covered by Medicare, and how much you will have to pay for them. This must be explained both by talking with you and in writing. You may be billed for

• medical services and supplies that Medicare doesn’t pay for, such as prescription drugs, and
• 20 percent of the Medicare-approved amount for Medicare-covered medical equipment such as wheelchairs, walkers, and oxygen equipment. If the home health agency doesn’t supply durable medical equipment directly, the home health agency staff will arrange for a home equipment supplier to bring the items you need to your home.

Note: If you are in the Original Medicare Plan, ask your supplier “Do you accept assignment?” Assignment could save you money. Call 1-800-MEDICARE (1-800-633-4227) and ask for a copy of Does your doctor or supplier accept ‘assignment’?

Medicare pays your home health agency a set amount of money for each 60 days that you need care. (This 60-day period is called an “episode of care.”) The payment is based on what kind of health care an average person in your situation would need.

If a home health agency denies, cuts back, or stops your care because it believes that Medicare won’t pay for home health care services that a doctor has ordered for you, the agency must give you a Home Health Advance Beneficiary Notice (HHABN). The HHABN should

• explain why the agency thinks that Medicare won”t pay for the services,
• explain that you may have to pay for the services if Medicare doesn”t pay for them, and
• give clear directions for getting an official decision from Medicare about the payment for home health services and for appealing the decision if payment is denied.

A home health agency must give you a HHABN that explains why and when it expects Medicare will stop paying for your home health care. If you get this notice and your doctor believes you still need home health care and that Medicare should keep paying, ask Medicare for an official decision. To get an official decision, you must

• keep getting home health care if you think you need it. Ask how much it will cost. Talk to your doctor and family about this decision.
• understand you may have to pay the home health agency for these services.
• ask the home health agency in writing to send your claim to Medicare so that Medicare will decide if it will pay.

If the Original Medicare Plan decides to pay, you will get back all of your payments, except for any coinsurance for durable medical equipment and any other costs for things that Medicare doesn’t cover.

If you are in the Original Medicare Plan, you can file an appeal if you think Medicare should have paid for, or didn’t pay enough for, an item or service you received. If you file an appeal, ask your doctor or provider for any information related to the bill that might help your case. Your appeal rights are on the back of the Medicare Summary Notice that is mailed to you from a company that handles bills for Medicare. The notice will also tell you why your bill wasn’t paid and what appeal steps you can take.

Medicare Advantage Plans, such as a Medicare Managed Care Plan, a Medicare Preferred Provider Organization, or a Medicare Private Fee-for-Service Plan, are health care choices in some areas of the country. In most plans, you can only go to doctors, specialists, or hospitals on the plan’s list. Medicare health plans must cover all Medicare Part A and Part B health care, including home health care.

If you belong to a Medicare Advantage Plan, you may only be able to choose a home health agency that works with the health care plan. Call your plan if you have questions about the plan’s home health care rules, coverage, appeal rights, and your costs. If you get services from a doctor or a home health agency that doesn’t work with your Medicare Advantage Plan, neither the plan nor Medicare will pay the bill. If you would like more information about Medicare health plans, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Or, look at your copy of the Medicare & You handbook mailed to all people with Medicare each fall.