Does Tricare Cover Home Health Care?

11 Jan 2022
Home health care costs vary based on care type, frequency, duration, and location. It may be covered by Tricare.

Home health care is an essential service for many people, especially for those who are recovering from illnesses or injuries. It can be costly, but for Tricare beneficiaries, home health care may be covered. Tricare is a health care program for military personnel and their families. It provides coverage for a wide range of medical services, including home health care. In this article, we'll explore what Tricare covers when it comes to home health care, and what you need to know if you're considering this option.

Is Home Health Care Covered by Tricare?

Yes, Tricare covers home health care services, but there are some limitations. Your physician must deem the services medically necessary. These services include skilled nursing care, physical therapy, and occupational therapy. Additionally, Tricare covers home health care services provided by a Tricare-certified agency.

Specific Home Health Care Services Covered by Tricare

Tricare covers a variety of home health care services that are deemed medically necessary by your physician. Some examples of specific services that may be covered include:

  • Skilled nursing care: This includes wound care, medication management, and other medical treatments that require the expertise of a licensed nurse.
  • Physical therapy: Tricare covers physical therapy services to help you regain strength and mobility after an injury or illness.
  • Occupational therapy: If you need assistance with activities of daily living, such as bathing or dressing, occupational therapy may be covered by Tricare.
  • Speech therapy: Tricare covers speech therapy for conditions such as stroke, traumatic brain injury, and developmental delays.

It's important to note that not all home health care services are covered by Tricare. It's best to check with your healthcare provider or Tricare representative to determine what services are covered under your plan.

What are the limitations?

There are some limitations to Tricare's coverage of home health care services.

  • Tricare does not cover custodial care, which includes services such as bathing, dressing, and feeding.
  • Tricare also does not cover home health care services that are provided by family members or friends.
  • Tricare has specific requirements for home health care services, such as the need for a physician's order and the requirement that the services be provided by a Tricare-certified home health agency.

How to Access Tricare-Covered Home Health Care?

Man in nursing home

To access Tricare-covered home health care services, you will need to follow these steps:

  1. Get a referral from your primary care physician. Your physician will need to determine that the home health care services are medically necessary and will provide the appropriate level of care.
  2. Select a Tricare-certified home health agency to provide the services. Ensure that the agency you choose is certified by Tricare.
  3. Tricare will cover the cost of the services as long as they meet the program's requirements.

How to Find a Tricare-Certified Home Health Agency?

Finding a Tricare-certified home health agency can be easy if you know where to look. Here are some steps to help you find a Tricare-certified home health agency:

  1. Use the Tricare Provider Directory: The Tricare Provider Directory is an online tool that helps beneficiaries find doctors, hospitals, and other healthcare providers that accept Tricare. You can search for home health agencies in your area that are certified by Tricare.
  2. Check with your Primary Care Manager (PCM): Your PCM may have a list of Tricare-certified home health agencies in your area that they can provide to you.
  3. Contact the Tricare Regional Contractor: Each region has its own contractor responsible for managing the delivery of healthcare services to beneficiaries. They can provide you with a list of Tricare-certified home health agencies in your area.
  4. Ask for recommendations: If you know someone who has received home health care services, ask them for recommendations on which agency they used and if they were satisfied with the care they received.

It's important to note that not all home health agencies may be certified by Tricare, so it's best to confirm their certification before receiving services from them.\

What if Your Primary Care Physician Doesn't Believe Home Health Care is Necessary?

If your primary care physician does not believe that home health care is necessary, it can be frustrating and confusing. However, there are steps you can take to advocate for yourself or your loved one's needs.

First, it's important to understand why your physician may not believe home health care is necessary. They may have concerns about the cost or whether the services are truly medically necessary. In some cases, they may simply not be aware of all the benefits that home health care can provide.

To address these concerns, consider discussing with your physician the specific reasons why you believe home health care is necessary. You can also provide information on Tricare's coverage of home health care services and how they meet their requirements for medical necessity.

If your physician still does not agree that home health care is necessary, you can request a second opinion from another healthcare provider. This may involve finding a new primary care physician who has experience with home health care or seeking out a specialist who can provide additional insight into your medical needs.

Ultimately, advocating for yourself or your loved one's healthcare needs can be challenging but it's important to remember that you have options and resources available to help you get the care you need.

Filing a Complaint or Appeal

If you disagree with a decision made by Tricare regarding your home health care services, you have the right to file a complaint or appeal. This process is in place to ensure that beneficiaries receive the appropriate level of care and that their rights are protected.

To file a complaint or appeal, follow these steps:

  1. Contact your Tricare regional contractor: The first step is to contact your Tricare regional contractor and explain why you disagree with the decision. They will review your case and provide guidance on how to proceed.
  2. File a formal appeal: If you are not satisfied with the regional contractor's decision, you can file a formal appeal. This involves completing a written request for an independent review of your case by an administrative law judge.
  3. Attend a hearing: If your case goes to an administrative law judge, you may be required to attend a hearing to present evidence and arguments supporting your position.
  4. Await the final decision: After reviewing all of the evidence presented at the hearing, the administrative law judge will make a final decision regarding your case.

It's important to note that filing a complaint or appeal can be time-consuming and stressful. However, it's also an important step in ensuring that beneficiaries receive the appropriate level of care and that their rights are protected under Tricare.

The Cost of Home Health Care Services under Tricare

Home health care services under Tricare can be costly, but they may be covered by the program.

Factors affecting cost

The cost of these services varies depending on several factors, including:

  • Type and frequency of care needed
  • Length of time care is required
  • Location where the services are provided

Cost-sharing arrangements

Tricare has different cost-sharing arrangements depending on the plan you have.

  • Beneficiaries enrolled in Tricare Prime are generally responsible for a copayment for home health care services. However, this copayment may be waived if certain conditions are met, such as if the beneficiary is homebound or has a chronic medical condition.
  • For beneficiaries enrolled in Tricare Select, out-of-pocket costs may be higher. These costs include an annual deductible and cost-sharing for covered services.

Additional fees

It's important to review your plan's specific benefits and costs to determine what your out-of-pocket expenses may be. Some home health agencies may charge additional fees not covered by Tricare. These fees could include charges for equipment or supplies used during treatment or additional services not deemed medically necessary by your physician.

Seeking information

If you're concerned about the cost of home health care services under Tricare, it's best to discuss your options with your healthcare provider or a Tricare representative. They can provide you with information on what services are covered under your plan and what costs you can expect to pay out-of-pocket.

How Long Will Tricare Cover Home Health Care Services?

The length of time that Tricare will cover home health care services depends on the medical necessity and the beneficiary's condition.

Plan of care

Your physician will prescribe a plan of care for your home health care needs, which will include the duration of services.

Coverage end

Once your physician determines that you no longer require home health care services, coverage will end. However, there are some circumstances where Tricare may approve additional coverage if you experience a setback in your recovery or require additional treatment due to unforeseen complications.

Extension of coverage

If you believe that you still require home health care services after your prescribed plan of care has ended, it's important to discuss this with your physician and seek approval from Tricare for an extension of coverage. Otherwise, you may be responsible for paying out-of-pocket for any continued services.

Summary

In summary, Tricare covers home health care services for as long as they are deemed medically necessary by your physician and meet the program's requirements. It's essential to work closely with your healthcare provider and Tricare representative to ensure that you receive the appropriate level of care and understand any potential out-of-pocket costs once coverage ends.

Preparing Your Home for Home Health Care Services

Preparing your home for home health care services can help ensure a safe and comfortable environment for both you and your healthcare provider. Here are some steps you can take to prepare:

  • Clear the Pathways: Ensure that pathways within your home are clear of any clutter or tripping hazards, such as rugs or loose wires.
  • Install Safety Equipment: Consider installing safety equipment such as grab bars in the bathroom, handrails on staircases, and non-slip mats in the shower or bathtub.
  • Make Necessary Repairs: Repair any damaged flooring, stairs, or railings that could pose a hazard to you or your healthcare provider.
  • Organize Medications: Create an organized system for storing medications to ensure that they are easily accessible and properly labeled.
  • Create Space for Equipment: If you require medical equipment such as oxygen tanks or wheelchairs, make sure there is enough space to store them safely.

By taking these steps, you can create a safe and comfortable environment for receiving home health care services. It's important to discuss any additional safety measures with your healthcare provider to ensure that all necessary precautions are taken.

Tips for Communicating Effectively with Your Healthcare Provider and Tricare Representative

Effective communication is key when it comes to ensuring that you receive the appropriate level of home health care services under Tricare. Here are some tips to help you communicate effectively with your healthcare provider and Tricare representative about your home health care needs:

Be Clear About Your Needs

When discussing your home health care needs, it's important to be clear about what you need and why. This includes being specific about the type of care you require, how often you need it, and any equipment or supplies needed.

Ask Questions

Don't be afraid to ask questions if there is something you don't understand. This can include asking about the qualifications of your healthcare provider, how your plan of care was developed, or what costs you can expect to pay out-of-pocket.

Keep Records

Keeping records of your home health care services can help ensure that you receive the appropriate level of care and that any issues are addressed promptly. This can include keeping a log of medications taken or recording any changes in your condition.

Stay Engaged

Staying engaged in your own healthcare is critical when receiving home health care services. This includes actively participating in developing your plan of care, attending all scheduled appointments, and reporting any concerns or issues as they arise.

By following these tips, you can help ensure that your home health care needs are met under Tricare and that you receive the highest quality of care possible.

Other Resources Available through Tricare

Tricare offers additional resources for beneficiaries who require medical assistance at home beyond home health care services. These resources include durable medical equipment and hospice care.

Durable Medical Equipment

Durable medical equipment (DME) is equipment that is used to treat a medical condition or illness and is designed to withstand repeated use. Examples of DME include hospital beds, wheelchairs, oxygen tanks, and walkers.

Tricare covers the cost of certain types of DME when prescribed by a physician and deemed medically necessary. Beneficiaries can receive these services through Tricare-approved suppliers.

Hospice Care

Hospice care provides comfort and support to individuals with terminal illnesses and their families. Hospice care can be provided in the home or in a hospice facility.

Tricare covers hospice care for eligible beneficiaries who have been diagnosed with a terminal illness and have a life expectancy of six months or less. Hospice care includes pain management, emotional support, spiritual support, and other services to improve quality of life during this difficult time.

If you or your loved one requires durable medical equipment or hospice care, it's important to discuss these options with your healthcare provider or Tricare representative to determine what services are covered under your plan and how to access them.

Conclusion

In conclusion, home health care services can be a valuable resource for Tricare beneficiaries who require medical assistance at home. By working closely with your healthcare provider and Tricare representative, you can ensure that you receive the appropriate level of care and understand any potential out-of-pocket costs.

It's important to note that Tricare's coverage of home health care services may vary depending on the plan you have and the specific medical necessity. If you have any questions or concerns about your coverage, it's best to discuss them with a Tricare representative.

Sources

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