Does my mother qualify for home health care?

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Photo by Getty Images

Photo by Getty Images

Editor’s Note: Journalist Philip Moeller, who writes widely on health and retirement, is here to provide the Medicare answers you need in “Ask Phil, the Medicare Maven.” Send your questions to Phil.

Moeller is a research fellow at the Center on Aging & Work at Boston College and co-
author of “How to Live to 100.” He wrote his latest book, “How to Get What’s Yours: The Secrets to Maxing Out Your Social Security,” with Making Sen$e’s Paul Solman and Larry Kotlikoff. He is now working on a companion book about Medicare. Follow him on Twitter @PhilMoeller or e-mail him at medicarephil@gmail.com.


Your Medicare Questions

Medicare rules and private insurance plans can affect people differently depending on where they live. To make sure the answers here are as accurate as possible, Phil is working with the State Health Insurance Assistance Program (SHIP). It is funded by the government but is otherwise independent and trains volunteers to provide consumer Medicare counseling in state and local offices around the country. The nonprofit Medicare Rights Center (MRC) is also providing on-going help.


Maria – Penn.: My mom has a Medicare Advantage plan that states that she has 35 hours of home health care. Unfortunately not one person at her insurer can clarify for me what these hours can be used for when needed. My mom is leaving a rehabilitation center, after having a stroke and broken pelvis and needs a home health aide to assist with bathing, transferring from bed to chair with a lift, changing a bandage from a deep wound, etc. I know she can use some of these hours for nursing care, physical therapy, and occupational therapy. Can any of these hours be used for home health care as outlined above?

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Phil Moeller: I’m sorry to hear about your mom’s health problems and your hassles in trying to find out how to get her the help she needs. It seems to me, and the experts at the Medicare Rights Center, that your mom qualifies for the type of home health care that you describe. I’ll explain the detailed requirements but first want to cut to the practical requirement: if you cannot get a straight answer from your mom’s insurer, you will need help. Her doctor’s office needs to take up her cause as well, including signing a statement about her need for the care. In an ideal world, someone there will know the bureaucratic ropes and help you. Also, you can call the MRC or your local SHIP office or even 1-800-MEDICARE (1-800-633-4227). Your mom’s Medicare Advantage plan has to offer the home health services required by Medicare. Plans are free to offer better benefits than basic Medicare (Parts A and B) but they cannot offer plans with inferior benefits.

Now, for the long answer. Would you expect anything less from Medicare? This comes courtesy of the MRC, and is addressed to the person needing care which, in your case, would be your mom.

Medicare will help pay for your home care if all four of the following are true:

1. You are considered homebound. Medicare considers you homebound if you meet the following criteria:

  • You need the help of another person or special equipment (walker, wheelchair, crutches, etc.) to leave your home or your doctor believes that leaving your home would be harmful to your health; and
  • It is difficult for you to leave your home and you typically cannot do so.
  • 2. You need skilled care. This includes skilled nursing care on an intermittent basis. Intermittent means you need care as little as once every 60 days to as much as once a day for three weeks (this period can be longer if you need more care but your need for more care must be predictable and finite). This can also mean you need skilled therapy services. Skilled therapy services can be physical, speech or occupational therapy. 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. Even when your other needs for Medicare home health end, you should still be able to get occupational therapy under the Medicare home health benefit if you continue to need it.

    3. Your doctor signs a home health certification stating that you qualify for Medicare home care because you are homebound and need intermittent skilled care. The certification must also say that a plan of care has been made for you, and that a doctor regularly reviews it. Usually, the certification and plan of care are combined in one form that is signed by your doctor and submitted to Medicare.

  • As part of the certification, doctors must also confirm that they (or certain other providers, such as nurse practitioners) have had a face-to-face meeting with you related to the main reason you need home care within 90 days of starting to receive home health care or within 30 days after you have already started receiving home health care. Your doctor must specifically state that the face-to-face meeting confirmed that you are homebound and qualify for intermittent skilled care.
  • The face-to-face encounter can also be done through a video connection. In certain areas, Medicare will cover examinations done for you in specific places (doctors’ offices, hospitals, health clinics, skilled nursing facilities) through the use of telecommunications (such as video conferencing).
  • 4. You receive your care from a Medicare-certified home health agency (HHA).

    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, which is probably what you were referring to in your question.
  • 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.
  • 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. (However, 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 percent of its approved amount for certain pieces of medical equipment, such as a wheelchair or walker. You pay 20 percent coinsurance, and could pay up to 15 percent if your home care provider does not accept Medicare’s approved fees.
  • As this last point makes clear, you also need to find out how the home health agency you select works with Medicare so that you won’t have any unpleasant billing surprises down the road.

    Paul – Colo.: I’m 62, retired, and lack the minimum credits (40) to qualify for Social Security, mainly because most of my work life was spent employed by federal and state governments which didn’t pay into the system on my behalf or require me to do so. Does my ineligibility for Social Security affect my benefits under Medicare? I have paid the Medicare payroll tax all along. Would it behoove me to go back to work to earn the minimum Social Security credits to qualify under that system, thus assuring full Medicare benefits?

    Phil Moeller: Paul, everyone is qualified for Medicare when they turn 65. The only question is whether they get free hospital coverage (Part A) or have to pay a premium of up to $407 a month to get it. The premium is less — $224 a month — if you or your spouse have at least 30 quarters of covered earnings — that is, how many quarters you have worked at jobs where they pay Social Security payroll taxes. And it’s free with 40 or more quarters of co-called covered earnings. However, Medicare clearly says that you are entitled to free Part A coverage if “you or your spouse had Medicare-covered government employment.” Because you say you’ve been paying Medicare payroll taxes, I’d think you’d qualify. Then again, if you are eligible for the Federal Employee Health Benefits Program, you may not even need to enroll in Medicare. If you have a spouse, see how their earnings record affects your entitlement for benefits. In any event, my common sense often is no match for Medicare’s rules, so check with your last government employer to make sure.

    Alice – Texas: I will turn 65 later this year and plan to enroll in traditional Medicare and purchase a Medigap supplement. Medigap Plans K and L are appealing because of their lower monthly premiums and the protection of annual out-of-pocket spending limits. But are they really a good choice? Would you create hypothetical cases where Plans K and L would make sense vs. Plan F?

    Phil Moeller: Well, I could, but they would run on nearly forever and would depend on the difference in premiums for the plans offered where you live. Of course, I don’t know what these might be. And the results still would be hypothetical. The simple answer is that if you are healthy with few healthcare needs, these lower-premium policies will save you money. And if you are sick with lots of healthcare needs, their annual caps on out-of-pocket spending will also save you money. The risk is that you will fall in the middle, as do most people. Remember that you are still paying the Part B premium and it’s not part of the out-of-pocket calculations here. And you need to factor in the costs of a Part D prescription drug plan. Also, please don’t forget that each letter plan offered by Medigap insurers offers the same coverage but that insurers are free to set their own premiums. So, whichever letter plan you select, careful premium comparisons are essential. These plans, also known as Medicare supplement policies, were explained in an earlier Ask Phil.

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