Skilled Nursing Care Services

Medicare and many other commercial insurances cover skilled nursing care when the services you need:

• Require the skills of a nurse.

• Are reasonable and necessary for the treatment of your illness/disease, surgical recovery or injury.

• Are given on a part-time or intermittent basis.

A registered nurse (RN) or a licensed practical nurse (LPN) can provide skilled nursing services. If you receive services from an LPN, your care will be supervised by an RN. Home health nurses provide direct care and teach you and your caregivers about your care. They also manage, observe and evaluate your care.

Physical Therapy, Occupational Therapy and Speech-Language Therapy Services

Therapy services are considered reasonable and necessary in the home setting if:

1. They are a specific, safe and effective treatment for your condition.

2. Your condition requires complex services that can only be safely and effectively performed by, or under the supervision of, qualified therapists.

3. Your condition requires therapy that is reasonable and necessary to restore or improve functions affected by your illness/disease, surgical recovery or injury.

4. The amount, frequency and duration of the services are reasonable and measurable.

A skilled therapist can safely and effectively establish a therapy program (if not already determined by your physician and their established protocol). A skilled therapist can also perform therapy under a maintenance program to help you maintain your current condition or to prevent your condition from getting worse.

Medical Social Services

Medicare covers these services when a doctor orders them to help you with social and emotional concerns that may interfere with your treatment or how quickly you recover. This might include counseling or help finding resources in your community. However, Medicare doesn’t cover medical social services unless you’re also getting skilled care as mentioned above. (Progressive Home Health can also check and verify to see if your specific commercial insurance company offers a “Medical Social Services” benefit within your plan.)

You can use your home health benefits if:

1. You’re under the care of a doctor, and you’re getting services under a plan of care established and reviewed regularly by a doctor.

2. A doctor certifies that you need one or more of the following:

• Intermittent skilled nursing care

• Physical therapy

• Speech-language therapy

• Occupational therapy

3. The home health agency caring for you is approved by Medicare (Medicare-certified) and/or a contracted provider through your commercial insurance plan.

4. A doctor certifies that you’re homebound. To be homebound means:

• You have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness/disease, surgical procedure or injury, or leaving your home isn’t recommended because of your condition.

• You are normally unable to leave your home, but if you do, it requires a major effort.

• You may leave home for medical treatment or short, infrequent absences for nonmedical reasons (e.g., church, occasional trip to the beauty/barbershop, attendance at a family event, or other infrequent or unique event). You can still get home health care if you attend adult day care or religious services.

5. As part of your certification of eligibility, a doctor or other health care professional must document that they have had a face-to-face encounter with you (like an appointment with your primary care doctor) within required timeframes and that the encounter was related to the reason you need home health care.

What isn’t covered under home health care benefits?

Here are some examples of what Medicare, and other commercial insurances, DO NOT pay for:

• 24-hour-a-day care at home

• Meals delivered to your home

• Homemaker services, like shopping, cleaning and laundry

• Custodial or personal care, like bathing, dressing and using the

bathroom, when this is the only care you need