Medicare Coverage of Skilled Home Health Care
If you qualify for the home health benefit, Medicare covers the following types of care:
- Skilled nursing services and home health services provided up to seven days a week for no more than eight hours per day and 28 hours per week (Medicare can cover up to 35 hours in unusual cases).
- Medicare pays in full for skilled nursing care, which includes services and care that can only be performed safely and effectively by a licensed nurse. Injections (and teaching patients to self-inject), tube feedings, catheter changes, observation and assessment of a patient’s condition, management and evaluation of a patient’s care plan, and wound care are examples of skilled nursing care that Medicare may cover.
The nine services, which apply to both skilled nursing facilities and to home health care, are:
- Intravenous or intramuscular injections and intravenous feeding;
- Enteral feeding (i.e., “tube feedings”) that comprises at least 26 per cent of daily calorie requirements and provides at least 501 milliliters of fluid per day;
- Nasopharyngeal and tracheostomy aspiration;
- Insertion and sterile irrigation and replacement of suprapubic catheters;
- Application of dressings involving prescription medications and aseptic techniques;
- Treatment of extensive decubitus ulcers or other widespread skin disorder;
- Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by nurses to adequately evaluate the patient's progress;
- Initial phases of a regimen involving administration of medical gases; or
- Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing that are part of active treatment, e.g., the institution and supervision of bowel and bladder training programs.
- Medicare pays in full for a home health aide if you require skilled services. A home health aide provides personal care services including help with bathing, using the toilet, and dressing. If you ONLY require personal care, you do NOT qualify for the Medicare home care benefit.
- Skilled therapy services. Physical, speech and occupational therapy services that can only be performed safely by or under the supervision of a licensed therapist, and that are reasonable and necessary for treating your illness or injury. Physical therapy includes gait training and supervision of and training for exercises to regain movement and strength to a body area. Speech-language pathology services include exercises to regain and strengthen speech and language skills. Occupational therapy* helps you regain the ability to do usual daily activities by yourself, such as eating and putting on clothes. Medicare should pay for therapy services to maintain your condition and prevent you from getting worse as long as these services require the skill or supervision of a licensed therapist, regardless of your potential to improve.
- Medical social services. Medicare pays in full for services ordered by your doctor to help you with social and emotional concerns you have related to your illness. This might include counseling or help finding resources in your community.
- Medical supplies. Medicare pays in full for certain medical supplies provided by the Medicare-certified home health agency, such as wound dressings and catheters needed for your care.
- Durable medical equipment. Medicare pays 80% of its approved amount for certain pieces of medical equipment, such as a wheelchair or walker. You pay 20% coinsurance (plus up to 15% more if your home health agency does not accept “assignment” - accept the Medicare-approved amount for a service as payment in full).
*If you only need occupational therapy, you will not qualify for the Medicare home health benefit. However, if you qualify for Medicare coverage of home health care on another basis, you can also get occupational therapy. When someone’s other needs for Medicare coverage of home health end, you should still be able to get occupational therapy under the Medicare home health benefit if you still need it.