Friday, April 30, 2010

6 Things You Need to Know About Medicare and Home Health

As a former home health organization CNO, I spent countless hours educating nursing staff as well as Medicare beneficiaries on what is covered under the Medicare Part A benefit for home healthcare. Many times I found that I was battling misinformation as a result of non home healthcare organizations not understanding the Medicare benefit. It is understandable since other healthcare facilities like hospitals and SNFs have their own regulations to follow. So I thought I would list the top 5 things every nurse, patient and other healthcare professionals need to know when suggesting home healthcare or referring individuals for home healthcare services.

1. Medicare will only pay for medical services on a short term, intermittent, part-time basis that are ordered by a physician and provided by (skilled professionals) licensed nurses, physical therapists, occupational therapists, speech language pathologists and medical social workers. Medicare does not reimburse agencies for services provided on a 24/7 basis nor do they cover service provided by a registered dietitian.

2. Medicare will only pay for home healthcare for patients that are considered homebound. Homebound is when the patient is confined to his/her home. An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. Home healthcare agencies have issues with this definition of homebound status. For a detailed summary with examples go to link section 30.1.1 - Patient Confined to the Home.

3. Medicare does not pay for patients only requiring (nonskilled) home health aide service. Many times patients will be referred to home health at time of discharge from a facility for extra help however the help that is needed does not require the service of a skilled nurse. Home health aide services are only covered when a licensed registered nurse and/or physical therapist is actively treating the patient for a medical condition.

4. Medicare does not reimburse agencies on an hourly basis. Medicare pays the agency on episodic fee for service basis and the lump sum payment covers all care that is provided for a 60 day period. It is up to the agency on how to manage the dollars allocated for the patient for this time period.

5. Medicare does not pay for long term home healthcare service. Any service that falls under the category of personal care, companion, and/or are considered long term care, custodial or domestic in nature is not covered. These are all considered nonskilled services that are typically supported by home health aides.

• Personal care focuses on long term care needs of a patient and include bathing, dressing, grooming, shaving, medication reminders, feeding/meal preparation, toileting, linen changes, laundry.

• Companion Care/Homemaker nonmedical/no touch care and focuses on services like reading, transportation, conversation and socializing, activities and games, meal preparation, laundry, and light house keeping.

6. Medicare does not pay for nursing visits that occur for the sole purpose of veni-puncture and obtaining blood samples. If the only need is for blood draws, then the patient will need to go to an outpatient center. However if the doctor orders more than just veni-puncture to include other skilled nursing interventions like assessment, observation and education related to disease process and the medication that requires veni-puncture and monitoring then it would be covered.

For more information about what Medicare will cover please visit:

For a more detailed explanation about what Medicare will cover from a home health agency operating perspective please visit:


  1. Dear Quiet Nurse,
    About one-quarter of Medicare beneficiaries today are enrolled in Medicare Advantage plans. Do the top 5 things apply to those beneficiaries, or do Medicare Advantage plans have the flexibility to alter the conditions?
    Really enjoy the blog and Twitter posts,
    Noisy Non-Clinician

  2. Dear Noisy Non-clinician,

    Thank you for following the blog and Twitter posts. Your question has triggered another idea for a blog. You highlight a very important point that Medicare Beneficiaries have the option of enrolling into Medicare Advantage plans. Medicare Advantage (MA) plans are offered by commercial (private) insurance plans like United, Aetna etc... and have the benefit of traditional Medicare coverage with additional options provided for additional fees. Types of Medicare Advantage Plans include:

    • Health Maintenance Organization (HMO),
    • Preferred Provider Organization (PPO),
    • Private Fee-for-Service (PFFS) Plans,
    • Medicare Medical Savings Account (MSA) Plans,
    • Medicare Special Needs Plans.

    The commercial insurance organizations are required to still abide by Medicare coverage limitations what is different is that instead of Medicare paying the healthcare provider directly, Medicare is paying the commercial insurance company to ensure the Medicare Beneficiary has access to cost effective healthcare service while ensuring quality patient care outcomes.

    Therefore some MA plans require referrals, preauthorization, and use of networked healthcare providers and organizations. Some MA Plans mimic the traditional Medicare program in coverage and reimbursement while the HMO plans tend to manage care more aggressively and reimburse the providers on negotiated fees.

    To answer your question which top 5 things still apply to MA plans - basically all apply but #4 related to reimbursement. Payment is based on the relationship between the commercial insurance company and the healthcare provider. Where the flexibility or ability to alter conditions apply is on the type of plan offered, if the commercial insurance company provides coverage on items not normally covered by Medicare, then the beneficiary will be responsible for additional co-pays, deductibles, coinsurance and premiums.

    The main point is that Medicare nor Medicare Advantage plans pay for long term care which most aging Medicare Beneficiaries typically need. If long term care is what is required whether it is in the home or at a nursing facility, then the individual needs long term care insurance coverage.

    For more information on MA plans visit

    For an example of MA plan coverage by a commercial insurer visit

    For more information on how to get long term care covered visit