If you’ve recently been hospitalized or otherwise at home, you can benefit from home health care. Medicare provides coverage, but the program is changing. Learn how these changes will affect your ability to get the care you need.
Covered Home Health Services
Medicare home health insurance is part-time rather than full-time. If you need care 24 hours a day, expect to pay out of pocket.
Qualified care can be covered if it is done less than seven days per week (up to 28 hours per week for qualified caregivers and / or home care assistants) or less than eight hours per day for up to 21 weeks. This period of cover can be extended under special circumstances.
Not all care is qualified. If someone with no medical training can do this, it is not considered qualified care. Qualified care for Medicare purposes includes the following:
It does not include home delivery of food, grooming (e.g. help with dressing, feeding or using the toilet) or housewife services (e.g. help with cleaning, washing or shopping).
Exceptions to the rule
Medical social services or occupational therapy alone are not enough to qualify for home health care alone. You must also use another qualified service to qualify for coverage.
Medicare requirements for home care
In order for Medicare to cover your home health care, you must demonstrate a medical need. In particular, you need to be homebound. This means that either you cannot leave your home unassisted, that it is recommended not to leave your home because of your illness (s), or that leaving your home is physically demanding.
This does not mean that you cannot leave your home. Medicare is not insured when you leave home for medical care, adult day care, or religious services. Short, rare absences for non-medical reasons (e.g. participation in a family event) should also not be offset against you.
A doctor or nurse will need to confirm that you are home. Certification is based on a face-to-face visit 90 days prior to home health care start or within 30 days of home health care start.
The certification describes your care plan over a period of 60 days. Recertifications must be reviewed and approved by your doctor every 60 days, but do not require additional in-person visits.
A Medicare certified home health agency must provide care or it will not be covered. To find a reputable agency near you, Medicare offers a searchable database under Home Health Compare.
Medicare Home Health Care expenses
It is estimated that 4.4 million Seniors are home-attached to Original Medicare (Part A and Part B), but only 11% of them received home care between 2011 and 2017.If youIn 2018, approximately 6.4 million Medicare beneficiaries were hospitalized who may need home health services.If youA total of 3.3 million people required home health services this year.If youIf you
Medicare spent $ 17.9 million on home health care in 2018.If youAccording to the Medicare Payment Advisory Commission, these payments exceeded the cost of the providers to administer these services. Home health authorities reported gains of up to 17.5% in 2017.If youIf you
To reduce Medicare spending, the Medicare Payments Advisory Commission recommended reducing payments to home health authorities by 5% by 5% in 2020. It was assumed that these agencies would continue to remain profitable and the payment cuts wouldn’t stop them from caring for Medicare beneficiaries.
Patient-driven grouping model
The PDGM (Home Health Patient Driven Groupings Model), which was launched on January 1, 2020, also tries to reduce Medicare costs. The aim is to move from a service model to a value-based model for home health care. PDGM values quality over volume and uses the following categories to determine how much Medicare pays for your home health services:If youIf you
- Approval source: Medicare pays home health authorities more if you were in an institutionalized facility (such as a hospital or nursing home) prior to starting services. Care from a community setting may offer lower reimbursements.
- Timed coordination: Instead of 60-day intervals, Medicare would review care in 30-day periods marked as early and late. Early care is likely to be more acute and likely to result in higher payments.
- Clinical grouping: They are divided into one of 12 groups including behavioral medicine, complex nursing interventions, medication management / teaching / assessment (MMTA, spanning seven categories), musculoskeletal rehabilitation, stroke rehabilitation and wound care. Different payment rates are set for each category.
- Malfunction: You are rated as low, medium, or high risk based on your ability to engage in activities of daily living (e.g., bathing, dressing, grooming, carrying, and walking). The higher the risk, the higher the payment.
- Comorbidity cessation: Pre-existing conditions can affect your clinical progress. PDGM recognizes this and increases payments based on the following ranking: none, low (one chronic condition), or high (two or more chronic conditions).
Advantages and disadvantages of PDGM
PDGM hopes to identify people with the greatest clinical need and those who will benefit from enhanced services. With concerns that some home health authorities may have billed unnecessary treatments in the past, it also aims to reduce the overuse of therapies for people who may not need or benefit from them.
Despite its good intentions, this model could backfire if health authorities choose their clients at home and prefer short-term therapy after a hospital stay or a stay in a rehab facility because it makes them pay more.
The Centers of Medicare & Medicaid Services (CMS) must carefully monitor outcomes to ensure that all Medicare beneficiaries have adequate access and continue to receive the care they need.
A word from Verywell
Millions of people use home health services every year. Changes to Medicare coverage in 2020 shifted the focus from the quantity of care to the quality of care.
The new value-based model disrupts home health care reimbursement. However, questions remain as to whether there are financial incentives for home health authorities to change the nature of the services offered or to limit the services for some Medicare beneficiaries. Contact your doctor if you think you could benefit from home health care.