What Medicare Covers

Home Health Services

Medicare pays for the full cost of medically-necessary home health care, including Nursing, Home Health Aide, Medical Social Work, Occupational, Speech and Physical Therapies, home-based Psychiatric Nurse Services and medical supplies, if certain criteria or met.

Please note this is a guide only. Check with your local home care agency to get coverage details.

Patients must:

• Be homebound (more on Homebound Status below)
• Need care that requires the skills of a licensed nurse or therapist
• Require care that is part-time and intermittent
• Require care that is reasonable & necessary for the diagnosis or treatment of a medical condition
• Have a plan of care signed by their physician
• Have an appointment with their physician within 90 days before or 30 days after the start of home health care for reasons related to the need for home health care.

Note: Medicare will pay for reasonable and necessary supplies, including ostomy supplies, and outpatient therapy when the needed equipment is too cumbersome to bring into the home. While Medicare is paying for a patient’s home health services, the patient must obtain any needed ostomy supplies or outpatient therapy through the home health agency. No ostomy supplier or outpatient therapy provider can receive payment from Medicare while the patient is receiving home health care and the supplier can hold the patient responsible for the charges.

Understanding Homebound Status

For a patient to be eligible for Medicare coverage of home health services, your physician must certify in all cases that you are confined to the home, i.e. homebound. Individuals are considered homebound if the following two criteria are met:

1. Criteria-One:
Because of illness or injury, you must either use supportive devices such as crutches, canes, wheelchairs, and walkers; need special transportation; or require the assistance of another person in order to leave your home.

OR

Your condition contradicts leaving your home.

If you meet one of the Criteria One conditions, you must ALSO meet two additional requirements defined in Criteria Two below.

2. Criteria-Two:
You must have a normal inability to leave home;

AND

Leaving home must require a considerable and taxing effort.

If you do leave the home, you may still be considered homebound and long as your absences are infrequent or relatively short. Absences that, by law, do not count toward homebound status are:

• Attendance at a state licensed adult day care facility
• Church
• Visits for medical treatment

You are considered homebound if the following two criteria are met:

The patient, because of illness or injury, needs the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; requires the use of special transportation; or the assistance of another person in order to leave their place of residence; OR have a condition such that leaving his/her home is medically contraindicated

(Source: Medicare Benefit Policy Manual)

Home Health Services Not Covered by Medicare:

• 24-hour-a-day nursing care at home
• Drugs and biologicals
• Meals delivered to your home
• Homemaker services
• Blood transfusions
• More than eight hours per day of combined nursing/aide
• Non-skilled nursing services

Hospice Care

Hospice is a patient-centered philosophy of care that includes expert medical treatment, pain and symptom management, and emotional and spiritual support specific centered around the wishes and needs of your or your family member.

Hospice care is available wherever you reside – a private home, extended nursing home, assisted living facility, the hospital, or in VNA’s Vermont’s Respite House in Willison.

When you or a family member is coping with a serious illness and a cure is no longer possible, hospice provides the type of care most people say they want at the end of life.

If you or a family member is in the last months of life, hospice allows you to live comfortably, surrounded by loved ones and familiar sounds and smells of home.

The Medicare hospice benefit pays for services every day and also permits a hospice to provide appropriate custodial care, including homemaker services and grief and bereavement counseling. Medicare Hospice also covers necessary medications and durable medical equipment.

Who is Eligible?

Medicare coverage for hospice is available only if:

• The patient is eligible for Medicare Part A.
• The patient’s doctor and Hospice Medical Director certify the patient is terminally ill with a life expectancy of six months or less.
• No further aggressive or cure-oriented treatment is desired or recommended.
• The patient and family understand hospice philosophy and the patient signs a statement choosing hospice care instead of standard Medicare or Medicaid benefits.

Hospice Covered Services

• Expert pain and symptom management from experienced nurses
• Medications related to your hospice diagnosis
• Medical supplies and equipment (e.g. hospital bed, oxygen, bedside commode, wheelchair)
• Personal care and comfort measures
• Respite for family caregivers
• Spiritual and emotional support for you and your family
• Homemaker services including light housekeeping, meal preparation, laundry
• Bereavement support for surviving family members
• Coordination of short-term inpatient care if pain or other symptoms become too difficult to manage at home

Hospice Private Insurance

Most private insurance plans also include a hospice benefit. The rules for eligibility and the benefits offered to differ for each plan. For details about hospice check the link below, or call your local hospice agency.