Skilled vs. Unskilled Home Healthcare

Do You Know the Difference?

There are two types of home healthcare

There are two types of home health care to choose from, and though they have many similarities, there are also some differences that could be the determining factors as to which one you will choose to meet your needs.

Unskilled services are not covered by Medicare, do not have to be ordered by a physician, are provided by a certified nursing assistant (CNA) or home health aide, and should be provided by a state-licensed agency. The State requires that the care provided be supervised by a Registered Nurse. The Registered Nurse performs an assessment of the patient, creates the plan of care, then visits intermittently to assess for changes and care provision being done by the CNA. Private pay is a primary source of reimbursement, along with Medicaid (eligibility required), .but there are also long-term care insurance policies that cover these services. Unskilled services include bathing, grooming, dressing, and personal care. It can also include homemaker tasks such as meal preparation, laundry, house cleaning, and errands. Most agencies require a minimum number of hours for care provision, such as in 4 hour increments, and can extend up to 24 hour care. Some also have Bed and Bathing Service where the time in the home is limited with no minimum number of hours required.

Skilled home care can be paid for by Medicare if you are eligible for those benefits, but certain criteria must also be met.

  • You must be homebound. Homebound means the patient is unable to leave the home without the assistance of another person, or an assistive device, and that it is a hardship to leave the home. Patients that can drive themselves are not usually considered homebound.

  • The care you need includes intermittent skilled nursing care, physical therapy or speech therapy.

  • The services are referred to the skilled home health care agency and must be ordered by a physician.

  • There is no charge for a nursing assessment when ordered by a doctor.

    If you need skilled nursing or therapy, you are also eligible for intermittent aide services, medical social worker, occupational therapy and some medical supplies. These services and equipment must also be ordered by the doctor. Medicare does not cover domestic, household or personal care needs when those are the only services needed. Most durable medical equipment is covered at 0%, so there is a 20% co-pay.

The skilled home health agency submits all claims to Medicare for the home health visits and those are covered at the full approved cost. You may be charged for services or costs that Medicare does not cover. Medicare sends you a statement of what the home health agency has submitted as the claim or the services you received. If you disagree with a decision on the amount or the services covered by Medicare, you have the right to appeal their decision. This information is provided to you when you are opened to service by the home health agency.

Most private insurance also pays for home health services, and, though many of them follow much of the Medicare criteria, each is individual in what their coverage will pay and you need to be in contact with your insurance representative to assure your coverage.