Medicare Home Care

To be eligible for Medicare home health visits, you must meet four conditions:

  • You must need care that includes part-time or intermittent skilled nursing care, physical therapy or speech therapy;
  • You must be "homebound," which means that leaving your home involves a considerable and taxing effort and absences from home are infrequent and brief;
  • Your physician must determine that you need home health care and must set up a home health plan for you; and
  • Medicare must certify the agency that provides your home health services.

If you meet all four conditions, Medicare will pay for skilled such as nursing care, physical therapy and speech therapy (except for a 20% co-payment for durable medical equipment such as a wheelchair or oxygen equipment).

Medicare may also pay for:

  • Occupational therapy;
  • Part-time or intermittent home health aide services, usually only one to two hours per visit;
  • Medical social services;
  • Medical supplies; and
  • 80% of the approved cost of medically necessary durable medical equipment prescribed by your doctor for use at home.

If you require more than part-time home health aide assistance, you will have to arrange for additional services. You must pay for this service or use another funding source such as Alternative Care or Elderly Waiver.

Will I receive a bill from the service agency?

No, not if you are covered by Medicare.

Medicare uses an intermediary to handle payments. The service agency sends bills to the intermediary, which is currently Blue Cross and Blue Shield of Wisconsin (414) 224-4954.

If the home health agency thinks Medicare will no longer cover your services, they will send you a letter called a Written Notice of Non-Coverage.

If you think Medicare will still cover your services, you may ask the agency to submit a "demand bill." If Medicare denies payment, you will be responsible for paying the home care bill or you may appeal.

Keep in mind that this process may take several months and you will be responsible for paying the bills incurred during the appeal.

However, government data indicates that about 40% of beneficiaries who appealed at the first level were given coverage and about 80% of those who appealed at the next level (administrative law judge) were found eligible for services.

If you have a complaint about your Medicare home health services that you have not been able to resolve with the agency, you may call the:

Minnesota Department of Health
Office of Health Facility Complaints
1-800-369-7994 or (651) 215-8713

or

Office of Ombudsman for Long-Term Care
1-800-657-3591 or (651) 431-2555