Help at home is probably the most-often-needed service for an older adult, and it’s the area where Medicare coverage is weakest and private costs are highest. Medicare does pay for some home healthcare services, however, under these conditions:
- A doctor confirms in writing that he or she has examined the person within 30 days and that the patient needs skilled nursing care, such as care provided by a registered nurse or physical therapist. Without this signed paper, the home healthcare agency cannot “open the case” (begin treating the person). The doctor can be a hospitalist or an emergency department doctor (employed by the hospital) or a community-based doctor. The visit must be face-to-face, not a phone conversation or a report from a nurse.
- If there is a documented need for skilled care, the person may also receive some home care aide services, although usually for a few hours a day or a few days a week.
- The person is homebound (meaning that leaving the house is hard).
- The person needs only short-term or part-time skilled services.
- The services are provided by a Medicare-approved home health agency (HHA). The HHA may have its own home health aides or contract with licensed agencies to provide these workers, but Medicare will not pay for services provided only by licensed agencies or companion agencies.
The so-called “improvement standard” (denial of physical or occupational therapy because the Medicare beneficiary is no longer making improvements) no longer exists (it was never a regulation even though it was commonly used). As a result of a lawsuit (Jimmo v. Sebelius) filed by the Medicare Advocacy Center, CMS has officially ended this practice. See the agency’s statement. The cap on reimbursement for these services has also been lifted, although providers are subject to a review of their fees if they reach a threshold of $3,000.
You can find more information from Medicare.