The Medicare Home Health Benefit

By: Sherry Netherland, Director of Special Projects for Assisted Healthcare Services

There has been a growing awareness in our country that long hospital stays are a thing of the past.  In the 50’s, my mother was in the hospital for two weeks when she had her children by C-section, now it’s a three day stay.  Even though some may feel that drive-through brain surgery is just around the corner, a short hospital stay is not necessarily a bad thing.   It is an accepted truth in the healthcare industry that patients have better outcomes if brought home early.  Part of the reason for this enhanced recuperation at home is the advent of home healthcare. Home healthcare can prevent, postpone or limit the need for individuals to receive healthcare services in the institutional setting.

The services allowed by Medicare home health benefits include: skilled nursing, physical therapy, occupational therapy, speech therapy, medical social worker, and home health aide (bath visits).

Medicare Criteria for Home Health Coverage:

You Must Be Homebound

This is defined as being unable to leave the home “at will.”  For some patients, home care is provided during that transitional period from hospitalization to outpatient care.

You Require Skilled Care

This is defined as care that falls within the scope of practice of a Registered Nurse, Physical Therapist and/or Speech Pathologist.  At least one of those three specialties must be on the case to qualify a patient as having a medical need as defined by their Medicare home health benefit.   Patients require services because of acute illness, long-term health conditions, permanent disability, or terminal illness.  Bath visits may be appropriate during the time skilled intervention is occurring, but once a patient is discharged from those skilled services, the Medicare covered bath visits end.

This skilled need criterion is the number one source of confusion for home care consumers.  If the only service needed is a bath, Medicare will consider that custodial care and not a covered benefit.  This usually comes as quite a shock when seniors need help with bathing and other activities of daily living and they learn that there is no Medicare coverage for this.  That type of care is only covered by private pay or other long term care insurance.

Your Home Health Need Is Medically

Medicare is designed to be restorative or rehabilitative, it is not a maintenance program.   If a patient reaches a plateau with no further improvement, even if they have not achieved pre-illness status, service must be discontinued.

Your Physician Determines All Care Is Necessary

A home health agency nurse is the eyes and ears of a doctor in the patient’s home.  The home nursing assessment and home care plan is a vital tool for the physician in directing patient care.

If you have any questions regarding the Medicare home care benefit and you live in Los Angeles, Ventura or Santa Barbara counties in California, contact your local Assisted office (www.assisted1.com) and they will guide you through the process.


Sherry Netherland, MA, is the Director of Special Projects for Assisted Healthcare Services, a Medicare certified, CHAP accredited home health agency with 7 branches in California and Arizona. She founded the Assisted Speakers Bureau and she speaks on a variety of healthcare related issues. To learn more about private duty nursing and how Assisted can help, www.assisted1.com/home_health_care.

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