Medicare Coverage of Home Health Care

elderly woman with home health care physical therapist

Many people mistakenly believe that Medicare provides coverage for long-term home health care. It doesn't.

Medicare covers only limited periods of skilled nursing care and therapy at home, and only if certain strict conditions are met. Still, Medicare's home health care coverage can be vital if the person you're caring for has suffered a serious medical event that suddenly changes his or her condition. Medicare can pay for costly short-term, intensive home care, which can give you a chance to arrange for longer-term care if it's needed.

Medicare or Medicaid?

One of the reasons many people mistakenly believe that Medicare covers long-term home care is that they confuse Medicare with Medicaid, which is a completely separate program only available to people who have very low income and few assets other than their home. Unlike Medicare, Medicaid can cover long-term home care, the amount and frequency depending on the patient's needs.

SEE ALSO: Find In-Home Care Help Near You

Who's eligible for Medicare coverage of home care?

Home health care can be covered by either Medicare Part A or Medicare Part B, each with slightly different rules. If the person you're caring for is enrolled in either Part A or Part B, he or she can receive home care coverage without any additional Medicare enrollment.

If the person you're caring for is enrolled in a Medicare Part C Medicare Advantage plan, it too will cover home care, at least to the same extent (described below) as Medicare Part A or Part B, and perhaps with somewhat broader coverage. Contact the plan directly to find out the exact terms of its home care coverage.

What kind of home care does Medicare cover?

If a patient needs home health care services such as skilled nursing or rehabilitation care at home, either Medicare Part A (following a minimum three-day hospital stay) or Part B (no hospital-stay requirement) can cover it. A Medicare Part C Medicare Advantage plan similarly covers home care. The care can be provided in the patient's home or anywhere else he or she stays. If a patient meets the requirements to qualify for home care (see next page), Medicare covers skilled nursing or rehabilitation care and physical and speech therapy as needed while the patient recovers from an illness, condition, or injury. Medicare also covers needed medical supplies and equipment.

If a patient needs only nonmedical home care and assistance, such as help with eating, dressing, walking, meal preparation, and housekeeping, Medicare does not cover it. However, if a patient is getting Medicare coverage for skilled nursing or therapy at home, Medicare usually pays for limited visits by an aide from a home care agency to help with personal care. If Medicare covers skilled home care for the patient, it also covers the services of an occupational therapist to help him or her relearn how to accomplish daily personal care and household tasks safely.

SEE ALSO: Find In-Home Care Help Near You

What’s Not Covered

Medicare insurance pays for physical and occupational therapy and speech language pathology services, counseling, some medical supplies, durable medical equipment (which must meet coverage criteria), as well as general assistance with daily activities which include dressing, bathing, eating, and toileting. For most other medical equipment, Medicare insurance will cover 80% of its cost.3

However, Medicare will not cover twenty-four hour care at home, meals delivered to your home, and services unrelated to your care such as housekeeping. Of course, as mentioned above, you will be required to pay 20% for medical equipment not fully covered by Medicare insurance such as wheelchairs, walkers, and oxygen tanks.4

In some cases, your home health care agency may send you a Home Health Advance Beneficiary Notice (HHABN), which, simply put, means if your agency is ceasing your care services, you will be presented with a written statement outlining the supplies and services the agency believes your Medicare insurance benefits will not cover as well as a detailed explanation of why. Should this situation arise, you do have recourse – the HHABN lists directions on acquiring the final decision on payment issues or filing an appeal if Medicare refuses to cover costs for home health care. In the meantime, you should continue receiving home health care services, but keep in mind that you will be paying for these services out-of-pocket until Medicare accepts your claims and remits past expenses.

What's Covered by Your Policy Therapy Services and Counseling Medical Supplies, Oxygen, Durable Medical Equipment & Approved Activities of Daily Living (dressing, bathing, eating, toileting) Wheelchairs, Walkers, and Oxygen Tanks 24-hr. Care, Delivered Meals, and Housekeeping
Medicare    
Covers 80% of Approved Equipment
 
Medigap    


(covered fully if used in conjunction with your Medicare plan)

(Coverage depends on which Medigap plan [A-L] you have)
Your Expenses    
(20% of outstanding costs)


(You are responsible for payment if you do not have a supplemental Medigap plan)

Medigap and Other Out-of-Pocket Expenses

Medigap, a supplemental insurance policy, is sold privately and covers the services and supplies not paid for by Medicare insurance. When used in conjunction, Medigap and Medicare can often cover a large majority of the costs of your home health care. Insurance companies offer a variety of different Medigap policies (A through L), but since each one comes with specific benefits, you'll need to compare the highlights closely. Medigap policies vary by cost, and many insurance companies require you to have both Medicare Parts A and B in order to purchase a supplemental plan.5

For seniors with both Part A and Part B Medicare, your home health care situation is usually covered, save for the 20% out-of-pocket expenses for medical equipment. Just remember to keep track of your Medicare insurance benefits (and Medigap if applicable) by verifying with your physician, home health care agency, and insurance representative. Paying for home health care does not have to cost you an arm and a leg, but do be prepared for the occasional (but necessary) out-of-pocket medical expenses.

How does someone qualify for Medicare home health care coverage?

For Medicare Part A or Part B to cover home health care services, several conditions have to be met:

  • Need for part-time skilled care: The patient must have a medical need for, and his or her doctor must prescribe, skilled nursing care or rehabilitative physical or speech therapy. The care must be needed part-time only, to help recover from an illness, injury, or acute condition. If, instead, the patient needs care because of a long-term condition or general frailty, Medicare won't cover it. Nor will Medicare cover full-time or daily care.

  • Confinement to home: Medicare covers home care only if and for as long as the patient is "confined to home." This means that the patient is unable to leave home without difficulty and with the assistance of another person or a medical device such as a wheelchair. However, it doesn't necessarily mean bedridden.

  • Recovery period: Medicare covers home care only while the patient is actively recovering, which means while his or her condition is improving. Once a patient's condition has stabilized, as determined by his or her physician, the home care agency, and Medicare, then home care coverage ends.

  • Medicare-approved agency: Medicare only covers home care provided by a Medicare-certified home healthcare agency. Unfortunately, this leaves out registry nurses, private therapists, and independent caregivers.

  • Medicare Part C Medicare Advantage Plans: A Medicare Part C Medicare Advantage plan must provide home care if the enrolled patient meet the conditions for coverage described above. But a Medicare Part C plan may provide some home care even if the patient doesn't meet all these conditions. To find out what the home care coverage terms and conditions are for a particular Medicare Part C plan, contact the plan directly.

How much does Medicare pay for home health care?

If a patient qualifies for Medicare coverage of home health care, Medicare pays the full amount of the home health care agency's charges, except for the rental cost of durable medical equipment such as a wheelchair or hospital bed, for which Medicare pays 80 percent. If a patient is enrolled in a Medicare Part C Medicare Advantage plan or has a Medigap insurance policy, that plan or policy may pick up this extra 20 percent for medical equipment; otherwise, the patient has to pay for it personally. The home care agency isn't allowed to bill patients for any amount above the Medicare-approved charges.

Medicare doesn't put any specific limit on the number of home care visits it will cover, nor on the total number of days a patient can be served by the home healthcare agency. But coverage will continue only as long as the patient meets all the qualifying conditions. A patient's condition and needs are regularly evaluated by the home care agency and by Medicare itself to determine how long skilled home care is medically needed and thus how long Medicare will keep paying.

Where can I get more information about Medicare coverage for home health care?

If the person you're caring for is in the hospital and you're looking for answers about follow-up care at home, contact the hospital's discharge planner, who arranges this type of care, or the hospital ombudsman, who's trained in Medicare issues and part of whose job is to help patients and families understand them.

You can also get information about home care coverage directly from Medicare's website or by calling (800) 633-4227. If the person you're caring for has been referred to a particular home care agency, the intake administrator for that service can also help with Medicare-related questions or problems.

If the person you're caring for has a Medicare Part C Medicare Advantage plan, contact the plan directly for information about home care coverage.


Joseph L. Matthews

Joseph Matthews is an attorney and the author of numerous books, including Social Security, Medicare, and Government Pensions, Long-Term Care: How to Plan and Pay for It; How to Win Your Personal Injury Claim; and The Lawyer Who Blew up His Desk. See full bio


about 1 year ago, said...

My Husband has been Disabled for 24 years and i recently found out my 8 year old daughter has autism Do i qualify for in home care?


about 1 year ago, said...

I am a registered nurse and I live in the home with my daughter, who has multiple sclerosis, who I give constant care , she is 43 years old, was dx with this disease at 36 years old. My life has literally stop to take care of my daughter as best as I can, I am not able to work my normal hours because of it. Can I get Paid to Be a Family Caregiver even though she's on medicare


about 2 years ago, said...

Is a family member eligible for home care benefits. My mother has early stages of dementia, she is blind an has limited mobility.


over 2 years ago, said...

I cannot find my diseases in your list, I have Transverse Myelitis & Sjogren's Syndrome do you have any information regarding In-Home Caregiver for someone confined to a hospital bed due to these conditions?


over 2 years ago, said...

I am recently disabled. I have harsh lower back and hip pain. I use a cane. Chronic migraines that last 1,3 or as long as 7 days and on average i can have as many as 10 or 12 a month. Memory lost and confussion are a big part of my day. Would these conditions make me eligible for SSDI? Would I qualify for Medicaid to pay my 23 year old son as my caregiver? We live in Atlanta, Georgia. He makes breakfast, reminds me which meds to take on time, makes medical appointments and does all heavy lifting. Before he came to visit me he said he noticed things were not right. He told me that I was skipping days when I should take meds and I was sleeping until 3 or 4 in the evening. Any suggestions or ideas?


over 2 years ago, said...

My daughter is on tencare and has a private duty CNT she's been with us for eight years we love her the company is horrible is there anyway our CNT can work self employed directly with ten care instead of through a agency


almost 3 years ago, said...

My mom has alzheimers I have had to give up my job to care for her,I am the sole caregiver and find it to be stressful that I have no down town.It costs a tremendous amount to have someone to come in to give me a break so therefore I am suffering many issues of burnout.I lpve my mother and give her quality care,but am beginning to lose patience from time to time and know i need to have a break Is there any groups that volunteer or maybe their is some assistance to cover occasional back up for me.Also I had to give up my job and have no personal income and would like to receive some compensation to help me with my personal expenses is that at all available and where to I need to apply if it is available.


almost 3 years ago, said...

I was considering getting a bathtub or new shower for safety reasons. I have taken about fiftey falls in my shower. Shower has glass doors and I Have had so many falls in there,I also a a garden tub in my other bathroom and I am so scared to use either of them because I have very dizzy spells and fall everywhere. Thank you. Sondra Cooper.


over 3 years ago, said...

The State of Washington claims that they don't need the use of "Skilled Nursing Care" for certain elderly or disabled patients needing care who receive Medicare or Copes program assistance. They, meaning Medicare Management are basically saying that against the laws of the State of Washington, Doctors orders can be passed down to a Home Care Agency who sends untrained workers out to care for patients they have no training skills to care for. Yet, the State will still financially reimburse contractors with tax payers dollars who are not expected to abide by State laws. This is very detrimental to the care of these vulnerable populations because they are not safe. I have informed The Centers for Medicaid Management Services in Washington State and they made this claim of non-supervision and no skilled nursing care by way of an RN as being acceptable even though CNA's, etc... cannot work without licensed supervision because it is against Washington State law.


over 3 years ago, said...

I myself am on disability for my MS. I take care of my mother who will be 92 in May. I need help. She has Medicare and Tricare for life. Can you help me find help.


over 3 years ago, said...

In my previous comment,.. I failed to also mention that many with home health care needs only require non-skilled help, known as a Home Health Care Aide. A Home Health Care Aide may help the resident with dressing, bathing, etc. Medicare does not pay for a Home Health Care Aide.


over 3 years ago, said...

My husband has been disabled for 24 years now..I have recently had to also take on his 48 year old mentily disabled brother because of health reasons..permatily.. I'm going to have to quit my job and take care of the 2 of them....I'm wondering if there is any finantical asestiance for myself as a full time caregiver...Does anyone know who I can contact?...


over 3 years ago, said...

Cost for housing with help. Only rich afford assisted living. I am on housing Voucher, now. Income yearly,$10,000. Food stamps of $54.00, cut $100 Last part of 2013, can't question. I am in frail health,poor prognosis . No family to help. I survive with credit cards,then not enough for food and Toliet paper,other personal. Medicaid won't help,I have to use brand name meds,dr. Ordered,I pay 20% with ins.pay for oxygen,dr, order,asthma uncontrolled,subject to anaphlatic shock,incurable life threat.would rather die than nursing home.Onocologist,says immune system not strong enough to fight germs in nursing home.can't drive . Am lost,is there help?


over 3 years ago, said...

My mother has had 2 strokes back to back. her mobility is very shakey and she has had a incident in the shower. will medicare pay for her a shower chair?


over 3 years ago, said...

I am full time caregiver for my 88 year old mom. Is there any financial assistance for immediate family member since I am not able to work in Ryder to take care of her. Is there any part time assistance covered by Medicare so I can do errands or work part time.


almost 4 years ago, said...

I am not clear on this can someone explain it to me better please. I am helping take of a woman that has breast cancer and she is on social security she is 65. Is there any programs that I can contact to help to get reimbursed for my work that I have been putting into helping take care of her. if so please let me know how to get the ball rolling. Thank you secretstitch


almost 4 years ago, said...

MY SPOUCE HAS ALZ. 100% BEDRIDDEN. I AM THE PRIMARY CARE GIVER. I HAVE BEEN TRYING TO GET HOME HEALTH. WHAT I AM GETTING IS THE RUN AROUND INSTEAD OF INFO. AND ANSWERS. SPOUCE HAS TRADITIONAL MEDICARE-MEDICAID-TENNCARE. GOT ANY IDEAS FOR US?


about 4 years ago, said...

my name is jeff, I live in Clearwater florida I had a stroke at 55 paralyzed on left side, I have va medical collect SSi and have medicade,i need aid and attendance or in home care with dressing, bathing ect, my wife is 47 but cannot work because she takes care of me she has no health insurance and has issues of her own but takes loving care of me. we try and survive on 710.00 a month im not eligible for va pension, does anyone have any ideas of programs that I can seek out for assistance like maybe a salary and medicade for her, or am I eligible for in home assistance so she can go to work? does anyone have any ideas that could help? besides praying a lot which we do a lot of, god bless anyone that can give me some guidence