How Does Medicare Handle Home Health Care for Dual-Eligible Beneficiaries?

Medicare handles home health care for dual-eligible beneficiaries by coordinating coverage through Medicare and Medicaid programs. Medicare usually pays first for covered home health services, while Medicaid may pay for additional costs or services not otherwise covered, helping minimize out-of-pocket costs for beneficiaries.

Dual-eligible beneficiaries comprise individuals who qualify for Medicare, a federal insurance program primarily for seniors, and Medicaid, a state and federal program assisting those with limited income, in covering their medical costs. The dual-eligibility status can provide significant benefits. It offers access to broader health care services, including home health care, a crucial service for those needing assistance while living at home.

For dual-eligible beneficiaries, Medicare usually serves as the primary payer for home health care services. These services include intermittent skilled nursing care, physical therapy and home health aide services. Medicare covers these services for homebound individuals if a doctor deems them medically necessary and prescribes them.

Medicare covers home health care under Part A (hospital insurance) and Part B (medical insurance). Eligibility for beneficiaries includes remaining homebound and under a doctor's care and requiring intermittent skilled nursing support or therapy services. If an individual meets these requirements, Medicare pays for a range of services, including:

• Intermittent skilled nursing
• Hospice care
• Physical therapy
• Speech-language pathology
• Medical social services
• Continued occupational therapy
• Preventative services
• Durable medical equipment
• Mental health services
• Some outpatient drugs

For dual-eligible beneficiaries, once Medicare pays its share, Medicaid can cover any additional costs, such as co-payments, coinsurance and services not fully covered by Medicare. This dual coverage ensures beneficiaries receive the necessary care without incurring significant out-of-pocket expenses. Medicare requires individuals to work with Medicare-certified home health care providers and receive services consistent with a care plan authorized by a health care professional.

Medicaid provides additional support by covering services and costs Medicare doesn't pay for. For example, Medicaid can pay for personal care services, which typically don't fall under Medicare coverage. These services can include help with activities of daily living, such as bathing, dressing and meal preparation, as well as household chore services and assistance with errands. Medicaid may also cover extended home health aide services beyond the scope of Medicare's benefits. To qualify for Medicaid, individuals must meet certain medical and financial requirements.

Each state administers its Medicaid program differently, so the exact benefits and eligibility requirements can vary. A beneficiary should contact their state Medicaid office or a health care provider to understand the available benefits. Aging and Disability Resource Centers provide further assistance with understanding and accessing Medicaid benefits, including counseling and help with preparing applications.