Medicare pays for "skilled" services that are "medically necessary." These services are the ones that can only be (by law) provided by a licensed healthcare provider; that is, a registered nurse, licensed physical therapist or speech therapist. When care is provided by one of these licensed practitioners, the services are usually covered by Medicare. You can then also have help from an occupational therapist, home care aide or medical social worker.
As you improve or stabilize, it is not uncommon for the "skilled" portion of the care to no longer be required. For example, an unlicensed practitioner (such as a home care aide) may be fully capable of providing all of the needed services. In most instances, these "less-than-skilled" services are not covered by Medicare but can be paid for directly by you. Your nurse or therapist will inform you when it appears that skilled services are no longer required so that appropriate plans can be made.
You must also be "homebound" in order for Medicare to pay for services. To be considered homebound, there must be a normal inability to leave the home. Absence from the home must be infrequent and of short duration to receive medical care. You are NOT homebound if you leave home frequently for business, work or school.
Face-to-Face Encounter Required by Medicare
A recent change in the law adds a new requirement to qualify for Medicare coverage. The new law requires that you be seen face-to-face by the physician, or certain non-physician practitioners working with the physician, before home care services start or soon thereafter.
The key elements of this new law are twofold:
- You must have the face-to-face visit within 90 days prior to starting home care or within 30 days after the start of care. Also, the visit must be for medical service related to the reason why home care services are needed.
- The physician responsible for performing the initial certification (admission or start of care) must include the date of the encounter.
It is your responsibility to be seen by a physician within this designated timeframe.