Medicare Home Health Services

Silver Tips is written by the Senior Citizens’ Law Office in Albuquerque.

Medicare beneficiaries who need home care should always look into whether they can qualify for home health services. It is not a general personal care or chore-worker service. Rather, Medicare home health covers limited, specifically defined at-home care related to identified medical conditions, and includes personal care services.

Medicare home health services must be prescribed by a physician, and provided through a licensed home health agency. The beneficiary must have a medical condition, or combination of conditions, that require periodic services from a skilled nurse or therapist. A plan of care will be developed that describes the specific services covered. Eligibility and coverage are evaluated strictly—sometimes too strictly, according to consumer advocates—so the beneficiary’s conditions and care needs must be aired fully.

To qualify for Medicare home health services, the beneficiary must first be found to be homebound. This means that leaving the home requires a considerable and taxing effort—for example, reliance on medical equipment and/or help from others—and that any absences from the home must be infrequent or of short duration. Medicare rules say that some specific activities, like going to medical appointments, religious services or adult day care centers, do not negate homebound status. However, these are just examples.

The skilled nurse or therapist visits must usually be needed at least once every 60 days. So long as those visits are needed, Medicare home health also covers services from home health aides, who provide personal care needed to facilitate treatment of the condition(s) identified, or to maintain the beneficiary’s health. The personal care can include help with ambulation and transfers, bathing, grooming, elimination, skin care, hygiene, feeding, linen changes, personal laundry, and light meal preparation. The number of home health aid hours will often be limited, for example, to a few hours a day, a few days a week.

Medical equipment and supplies, medical social services, and additional “incidental” personal care can also be covered. Everything depends on what is included in the plan of care, so detailed communication with the doctor and home health agency about the beneficiary’s needs is very important. Plans of care are reviewed at least every 60 days; care can continue as long as it continues to be found reasonable and necessary.

Decisions regarding eligibility for, and amount of, Medicare home health services can be appealed. Once a New Mexico beneficiary begins receiving home health services, s/he has a right to a hearing before the services can be terminated!! Individuals can call a toll free hotline to complain about Home Health Agencies or find out more information about them. The number—1-800-752-8649—also is used to receive complaints about other types of health facilities.

Additional information about Medicare home health coverage can be obtained from local Home Health Agencies, as well as from the New Mexico Aging and Long-Term Service Department’s “HIBAC” Medicare and benefits counseling program (statewide toll free 1-800-432-2080).