For Coloradans who are aging in place, they may at times have need for medical services provided in the home. Since it is commonly understood that “home health care” is not something Medicare covers generally, that leaves a question of whether or not Medicare will ever pay for in-home services. The answer is Yes — but with qualifiers, as you might expect. In this article we will cover the key things to know, including who can qualify for paid services and under what conditions.

Medicare traditionally covers a wide range of services under parts A and B, including hospital stays and visits to your primary care physician. These services typically require you to leave your home to get diagnosed and/or treated. But what if it’s difficult or close to impossible for you to go anywhere? What if leaving home might worsen your condition? This is where Medicare can step in for you to get paid treatment by skilled workers and therapists without having to leave the comfort of your home.

Range of services provided for In-Home Care in Colorado

Home health care covered by Medicare may include but is not limited to:

  • Skilled nursing care done by licensed nurses. Examples might be dressing wounds, rehabilitation ordered by a physician, changing feeding tubes, catheters, IVs, etc. Medicare specifies these must be “part-time or intermittent” care services, meaning they are provided less than eight hours per day or less than 28 hours per week (up to 35 hours in limited situations).
  • Durable medical equipment or medical supplies for use at home.
  • Physical therapy to help rehabilitate or treat conditions such as arthritis, broken bones, or other physical injuries.
  • Occupational therapy to help with everyday tasks for which your ability is compromised. This can range from something as simple as handling kitchen utensils to grooming and eating to operating a wheelchair.
  • Speech therapy, in which speech-language pathologists help diagnose, assess, and re-develop speech in people who need it. This may be needed, for example, after suffering a stroke.
  • Nutrition care to ensure you’re eating properly.
  • Medical social services, to connect you with assistance programs that help you manage health-related impacts you have experienced and to ensure you are being treated honestly by others who may be involved with your care situation.

“Homebound” defined

Medicare covers home health services “as long as you need part-time or intermittent skilled services and as long as you are ‘homebound.’” Here “homebound” means:

  • You have trouble leaving your home without help (such as needing a walker, wheelchair or crutches. Or you need special transportation or help from someone else due to an illness or injury.
  • Leaving home isn’t recommended because of your condition.
  • You’re normally unable to leave your home because it is a major effort to do so.

Timely, predictable improvement expected for in-home care in Colorado

Medicare requires that a doctor or other provider must see you face-to-face before certifying your need for home health services, and a Medicare-certified home health agency must provide it. Plans developed by doctors, which can include any of the above-listed services, are evaluated every 60 days, or sooner if an intense program requires that level of attention. Medicare does say that to receive these in-home services, “your condition must be expected to improve in a reasonable and generally predictable period of time.”

Covered home health services cost you nothing out of pocket, except for whatever deductibles and copayments you pay for under your Medicare plan, if these are not covered by other insurance, such as a Medicare supplement policy. The only other extra cost you’ll have for home health services is 20 percent of whatever durable medical equipment is needed for your services. Medicare covers the other 80 percent under your Part B plan.

So what isn’t covered?

Not all services that might generally fall under a generic title of “home health care” are covered by Medicare. Services not covered include:

  • 24-hour skilled nursing care. Remember covered services must be “part-time or intermittent.” Full-time skilled nursing care is provided in a skilled nursing facility or nursing home. With limited exceptions, Medicare does not pay for services in such facilities.
  • Meals delivered to your home. Medicare doesn’t pay for meals brought to you because you can’t leave the house. But note that a nutritionist looking after your healthy eating will be paid for if your doctor sees the need.
  • Custodial care, when it’s the only service you need. This refers to non-medical help, such as with bathing or getting dressed. However, this type of care might be included if your doctor deems it necessary to improve your condition.
  • Homemaker services. This includes activities such as shopping, cleaning, and laundry. Again, this might be covered if the home health plan prescribed by your doctor calls for it.

How do you qualify for in-home care in Colorado?

In addition to some of the criteria already mentioned that make you eligible for Medicare-covered home health care, how do you actually qualify for the services? As you would expect, you can’t simply choose on your own to have nursing care and other therapy services provided in your home.

The most important part of qualifying is that your doctor says you need in-home care. It is very much like he or she is writing a prescription for it. The doctor will specify the services you need (see bulleted list near the top of this article). This must be a Medicare-approved doctor whose care you are under. The doctor doesn’t have to be present at every home health visit. In practice, a home health nurse specialist will typically administer your plan, which will be reviewed regularly.

As noted earlier, you must be “homebound” as defined by Medicare. Besides general mobility constraints, being homebound can also mean you require assistance from a person or piece of durable medical equipment (DME) such as a walker or wheelchair to get around the home. A doctor can deem that you’re homebound if he or she believes that your illness or condition could get worse if you left the home.

To be paid for by Medicare, your in-home services must be provided by a Medicare-approved home health agency. Your doctor may have recommendations for such agencies. Not all in-home care companies provide the same services. Some may specialize in only a few services; others will offer every service you need. You may have to contact multiple companies in order to get all the services you need.

Medicare suggests asking a few pertinent questions when evaluating agencies. Such as:

  • Is the agency Medicare-certified?
  • Does it offer all the services you need, including physical and occupational therapy?
  • Did your doctor recommend it?
  • Do they have staff that can assist you in an emergency or time of need?
  • Does the agency fit your personal needs, like a language barrier or physical needs?
  • Are there patient and family reviews of the agency and its services that you can examine?

It’s important to do a thorough assessment of agencies before choosing one. You want to avoid needing to find a different one when you find out after the fact that they cannot provide all the therapies and other support you need or, worse, you learn they are not Medicare-certified and your costs are not covered.

You can research and compare home health agencies in the Colorado area on the Medicare site at https://www.medicare.gov/care-compare/?redirect=true&providerType=HomeHealth. You can find reviews and star ratings administered by Medicare, which are based on how well the agencies perform, their price points, and customer reviews. You can also learn which agencies are at risk of being terminated, and you can file complaints as well if that need should arise.