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.
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.
What’s not covered by Medicare
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.
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.
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:||Medicare||Medigap||Your Expenses|
|Therapy Services and Counseling||Covered||-||-|
|Medical Supplies, Oxygen, Durable Medical Equipment & Approved Activities of Daily Living||Covered||-||-|
|Wheelchairs, Walkers, and Oxygen Tanks||Covers 80% of Approved Equipment||Covered fully if used in conjunction with your Medicare plan||20% of outstanding costs|
|24-hr. Care, Delivered Meals, and Housekeeping||Not Covered||Coverage depends on which Medigap plan you have||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.
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.