Medicare Benefit and Eligibility Requirements

Skilled home health care services are a covered benefit under Medicare Part A. Home Therapy Austin is a certified Medicare provider and serves patients that have traditional Medicare Part A and Part B coverage as opposed to a Medicare HMO or Advantage Plan. Medicare covers 100% of the cost of skilled home health if the beneficiary meets the eligibility criteria.

To be eligible for Medicare home health services, the senior must:

1. Have a medical necessity for at least one skilled service which includes either skilled nursing, Physical Therapy or Speech Therapy as attested to by the physician ordering home health.

2. A physician must order the home health service and be willing to direct the patient’s home health care throughout the home health episode.

3. The patient must be homebound due to illness or injury. Homebound means that the patient is unable to leave the home without a considerable and taxing effort and absences from the home are infrequent and of short duration. Absences for the purpose of medical appointments, religious services, hair appointments are deemed to be absences of infrequent or short duration. Home Therapy Austin considers seniors who are driving not to be homebound.

4. The senior must have had a face to face encounter with the physician ordering home care or a Physician Assistant or Nurse Practitioner (or hospital physician) for the reason home care is being ordered either 90 days prior to the home health admission or within 30 days after the admission. The physician must complete a document certifying the encounter occurred.

5. The care is provided by a home health agency that has been certified by the Centers for Medicare and Medicaid.

To remain eligible the patient must actively respond to the care provider and remain compliant with the instructions provided by the clinical professionals providing the care and treatment.

Part A Medicare pays for a 60 day episode of care. If the patient, has not reached the goals established at the beginning of care but, is making progress towards the goals, if the clinical need exists and the physician agrees, the patient may be recertified for a subsequent episode or episodes of care.

At this time, there is no limit to the home health benefit. It is not capped at a specified dollar amount.

Patients HAVE THE RIGHT TO CHOOSE the Medicare provider they prefer. The patient simply needs to tell the physician or hospital staff that he/she has a home care preference and the selection must be honored.

Some patients are eligible for home health services, including physician visits, through the benefit offered in Medicare Part B which also reimburses the physician for review and management of the patient’s care plan for home health. Part B coverage requires a co-pay of 20% of the fee payable to the physician.

All Medicare certified home health agencies must report outcomes data and these outcomes are publicly reported on the Medicare website, http://www.medicare.gov/HomeHealthCompare/search.aspx.

Medicare Health Maintenance Organizations (HMOs) are privately administered Medicare plans. Most often these are administered by commercial insurance providers. Many seniors were enrolled in an HMO plan during the Medicare Prescription Drug enrollment. Depending on the plan, a Medicare HMO may restrict the number of home health visits and require prior authorization or approval before the care can be provided. The HMO may limit the doctors, hospitals and home health agencies that are used. It is important for Medicare beneficiaries to understand the type of Medicare coverage they have and what the coverage is before enrolling. Typically, a beneficiary can change plans in November or can move from a HMO plan to traditional Medicare.