This is the twenty-sixth in a series of articles intended to demystify retirement living options.

If you want to stay in your home but have medical conditions that make caring for yourself tricky, what services can help you?

Available services fall into three major categories: medical services, para-medical services, and non-medical services. This article focuses on medical services, also known as home health services.

This article assumes that the individual who needs services is age 65+ and is enrolled in Medicare, the federal health insurance program for the elderly and disabled.

Home health services are covered at no cost to enrollees in traditional Medicare if four conditions are met:

• The first is that the individual is homebound. Interesting, “homebound” doesn’t mean that the person never leaves home. Medicare explains its definition:
  • “Leaving your home isn’t recommended because of your condition. Your condition keeps you from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person). Leaving home takes a considerable and taxing effort.
  • “A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as attending religious services. You can still get home health care if you attend adult day care, but you would get the home care services in your home.”
• The second condition is that you are under a doctor’s care, and the doctor has created and regularly updates a plan of care for you.
• The third is that your doctor certifies that you need “intermittent” skilled nursing care (meaning that you don’t need skilled nursing all -- or even most of -- the hours in a day), physical therapy, occupational therapy, speech therapy, and/or medical social services.
  • Generally, the care must be medically necessary, recognized as appropriate for the individual’s condition, and require a skilled caregiver to deliver it.
  • Medicare will even pay for help with bathing, dressing etc. if the doctor certifies your need -- but only if you are getting other higher-skilled services such as skilled nursing care.
• The fourth condition is that the care must be provided by a home health agency that is Medicare-certified.

Explanations follow for some of the terms that Medicare uses.

“Examples of skilled nursing care include: giving IV drugs, shots, or tube feedings; changing dressings; and teaching about prescription drugs or diabetes care. Any service that could be done safely by a nonmedical person (or by yourself) without the supervision of a nurse, isn’t skilled nursing care.”

Medicare doesn’t cover full-time skilled nursing care, and it draws the line well before 24/7. For example, if you need care more than eight hours a day seven days a week, Medicare will not pay.

Medicare defines physical therapy as “treatment of injury and disease by mechanical means, such as heat, light, exercise, and massage.”

Occupational therapy, contrary to popular belief, does not necessarily have anything to do with performing a job for pay. Medicare defines it as “services given to help you return to usual activities (such as bathing, preparing meals, and housekeeping) after illness either on an inpatient or outpatient basis.”

Speech therapy addresses issues not only with speaking but also with swallowing.

Medical social services “help you with social and emotional concerns related to your illness. This might include counseling or help in finding resources in your community.”

Medical supplies are also covered if they are “essential items that the home health team uses to conduct home visits or to carry out services the physician has ordered to treat or diagnose a patient's illness or injury. . . . The home health agency provides these supplies for their use with the patient.”

Personal care, or “home health aide services” assist you with “daily living activities,” generally considered to be bathing, dressing, using the toilet, eating, moving from one place to another (e.g., bed to chair), and walking.

Most commonly, services are provided for perhaps an hour or two a few times a week.

Medicare explains its requirements and what home health services are covered in a brochure available at: http://www.medicare.gov/Pubs/pdf/10969.pdf.

Definitions of terms are also given in the Medicare glossary found at: http://www.medicare.gov/Homehealthcompare/Resources/Glossary.aspx.

The next column discusses home health agencies.

-- Next -- 107. How to Select an Agency to Provide Medical Care in Your Home