Frequently Asked Questions
Home health care is a confusing area, especially when insurance and/or government programs are involved. We know this can be a source of stress for many people, so we've compiled some of the most frequently asked questions.
Medicare coverage for home health care is available to people who have a normal inability to leave home (aka "homebound") and require skilled nursing and/or therapies. Six disciplines are cover-able (Skilled Nursing, Physical Therapy, Occupational Therapy, Speech-Language Pathology, Hole Health Aide and Medical Social Services).
Legally, there are no limitations to the duration or amount of covered services. The beneficiary must meet certain qualifying criteria to obtain these benefits.
Insurance will cover 100% of the cost if the client has Medicare as a primary payer. Medicare HMO plans will cover a portion of the cost, but usually, require a co-pay by the client depending on the insurance policy. Some Medicare Managed Care plans will cover the first 60 days of care at 100% before requiring an out of pocket payment by the beneficiary.
Prerequisites for Medicare Entitlement for Home Health Care
- Patient is under the care of a physician.
- Patient requires skilled nursing, physical therapy, occupational therapy or speech therapy on an intermittent basis.
- Patient qualifies for Medicare.
- Care is medically reasonable and necessary.
- Patient is homebound.
- Patient's needs can be met on an intermittent or part-time basis.
- Patient resides in a home or facility that does not perform skilled care (may reside in ALF community or memory care facility).
- A plan of care is rendered that includes measurable goals with indicators for marked progress & is under the guidance of a physician. Physical therapy, speech-language pathology, or continued occupational therapy services. These services are covered only when the services are specific, safe and an effective treatment for your condition. The amount, frequency and time period of the services needs to reasonable, and they need to complex or only qualified therapists can do them safely and effectively.
To be eligible, either:
- Your condition must be expected to improve in a reasonable and generally predictable period of time, or
- You need a skilled therapist to safely and effectively make a maintenance program for your condition, or
- You need a skilled therapist to safely and effectively do maintenance therapy for your condition.
You have trouble leaving your home without help (like using a cane, wheelchair, walker or crutches; special transportation; or help from another person) because of illness, injury or cognitive deficits. Leaving your home isn't recommended because of your condition, and you are normally unable to leave your home because it is a taxing effort. You may leave home for medical treatment or short, infrequent absences for non-medical reasons like attending church services. You can still get home health if you attend adult day care, if you live in assisted living, or if you live in a memory care facility. Driving infrequently does not mean you are not homebound.
Always check the Center for Medicare Advocacy for any updates to this definition.
A home health certification period can range from 1-60 days. The patient must need skilled care on an intermittent basis (less than 7 days per week but at least once every 50 days). Daily skilled nursing care is available for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional daily skilled nursing is finite and predictable). Client's can qualify for more than one 60 day episode of care if the qualifying criteria still exists.
- Intermittent Skilled Nursing: Nursing that is provided less than daily (seven days per week) or daily, for up to eight hours per day, for periods of 21 days or less (with extensions possible in exceptional circumstances, when the continued need for daily care will end in a predictable period of time.) Nursing and Home Health Aide services combined can be covered up to 28-35 hours per week.
- Home Health Aides: Personal care services in short duration for personal care and bathing to facilitate the intermittent skilled service.
- Physical Therapy (PT): Skilled therapy by or under the supervision of a skilled physical therapist.
- Speech-Language Pathology (SLP) (Also referred to as Speech Therapy (ST)): Skilled SLP by or under the supervision of a skilled speech-language pathologist.
- Occupational Therapy (OT): Skilled OT by or under the supervision of a skilled occupational therapist.
- Medical Social Services: To resolve possible social/emotional impediments to effective treatment or rate of recovery. This includes services to maintain an individual’s condition or slow decline. Medical Supplies: Items that are essential to enable home health agency personnel to effectively carry out ordered care.
- Durable Medical Equipment (DME): As in other situations, DME furnished by a home health agency is subject to a 20% coinsurance. Services Included in the Physician’s Plan of Care But Not Available from the Home Health Agency: Home health agencies that are not able to provide all the Medicare-coverable care included in the patient’s Plan of Care, are required to make arrangements with other providers to provide the care.
We are licensed in St. Charles, St. Louis, Warren, Lincoln and Franklin Counties.
Medical dictionaries define palliative care as care that affords relief, but not cures. Curative care, on the other hand, is defined as care that tends to overcome disease and promote recovery. Under your Medicare Part A benefit for skilled home health services, we can receive physician orders and direction from a palliative care provider who is working under your Medicare Part B benefit.
This will include all aspects of skilled care but will deliver services in conjunction with interventions for education, pain management and safe personal care and mobility. Once your physician has determined Hospice services are indicated, your Medicare part A benefit will transfer to a hospice provider of choice. Palliative care is for anyone with a serious illness and provides additional support to the patient and family.
In the early stages of a serious disease, a person may work with a palliative care team to promote access to disease-related specialists, develop a life care plan, and receive emotional and psychological support.
A patient can obtain palliative care at any age and at any stage of a serious illness. Palliative care is not dependent on prognosis and can be provided along with curative treatment. Such patients would not qualify for hospice services.
Hospice care is available for Medicare beneficiaries who are certified by a hospice physician as having a life expectancy of six months or less if the terminal illness runs its normal course.
Hospice care is provided by an interdisciplinary team (IDT). The core team, as defined by the Medicare Hospice Benefit (MHB), includes physicians, nurses, social workers, and bereavement counselors. These team members are required to provide care for every patient.
The broader team includes providers of therapy services (eg, physical therapy, occupational therapy, and speech therapy), home health aides, chaplains, volunteers, dieticians, and pharmacists, as well as others involved in customizing appropriate care for each individual. Each hospice agency has its own approach, providing unique blends of care.
Our therapy team can continue services if your hospice agency approves therapy in short duration or if you are able to pay for services privately.
Home health care is a wide range of healthcare services that can be given in your home for an illness or injury. Home health care is usually less expensive, more convenient, and just as effective as the care you get in a hospital or skilled nursing facility (SNF).
Examples of skilled home health services include: Wound care for pressure sores, stasis ulcers or a surgical wound; patient and caregiver education; intravenous or nutrition therapy; injections, pain management; unstable emotional health or adjustments to new medications; monitoring serious illness and unstable health status; safe mobility, ambulation, transfers, personal care and daily activities.
The goal of home health care is to treat an illness or injury and return a client to their prior level of function before the new onset or acute exacerbation of the illness or injury affected their ability to manage their health independently. Home health care helps you get better, regain your independence, and become as self-sufficient as possible.
Our goal is to provide long-term sustainable outcomes for optimizing the quality of life.
Envision Health Partners provides resources to improve the physical, social & emotional health of our members by providing preventative health services, socialization and a continued relationship that embraces a healthy lifestyle.
Our licensed and certified professionals deliver exercise & fitness classes, therapeutic massage, pain management, and enrichment programs. Our care partners provide easy access to an independent health care professional in one convenient location: chiropractic care, mobile dentistry, podiatry, nutritional services, health screenings and educational events.
Our health & comfort home furnishing designers create a healthy, safe and independent environment through liquid, stain, and bacteria resistant fabrics, durable finishes and furniture that is specifically designed with proper height, depth and firmness to increase function with transfers and mobility.
Wellness services can be accessed remotely or at home.
Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical and occupational therapy, and speech-language pathology services.
There are limits on these services when you get them from most outpatient providers. These limits are called “therapy caps” or "therapy cap limits.
$1,980 for physical therapy (PT) and speech-language pathology (SLP) services combined
$1,980 for occupational therapy (OT) services
Traditional Medicare, Coventry, and Aetna.
As a person with Medicare, you have certain guaranteed rights and protections. In addition, federal law specifies that patients of a Medicare-approved home health agency also have the following rights.
The home health agency must give you a written copy of them.
- Choose your home health agency. (For members of managed care plans, choices will depend upon which home health agencies your plan works with.)
- Have your property treated with respect.
- Be given a copy of your plan of care, and participate in decisions about your care.
- Have your family or guardian act for you if you are unable.