Would Medicare cover services recommended by an in-home evaluation?

1 answer | Last updated: Sep 14, 2017
A fellow caregiver asked...

If my mother's doctor who does accept Medicare writes an order for a in-home evaluation by Homecare services, would the evaluation and any services they deemed necessary be cover by medicare? Can we have her enrolled in an Advantage plan like the one I have with Humana? Would that help in any way?

Expert Answers

If your mother's doctor orders an in-home evaluation by a home care agency, that evaluation would almost certainly be covered by Medicare Part B. But whether Medicare would cover any services the agency recommended, even if prescribed by your mother's doctor, is more complicated. Medicare coverage for home care services is very limited. In general, Medicare would only cover home care if your mother needs skilled nursing or rehabilitation care but not if she needs long-term home care based on her inability to care for herself.

If your mother qualifies for Medicare coverage of home care, that coverage can include skilled nursing care and physical and speech therapy as needed as long as she is recovering, as well as needed medical supplies and equipment. Medicare doesn't generally cover nonmedical at-home care and assistance, such as meals and housekeeping. However, if your mother received Medicare coverage for skilled nursing or therapy at home, Medicare generally would also pay for limited visits by an aide from the home care agency to help her with personal care. Care may only be provided by a Medicare-certified home care agency.

For Medicare Part A (following a three-day hospital stay) or Medicare Part B (no hospital stay required) to cover home care for your mother, several conditions have to be met:
   • Your mother must have a medical need for part-time (no full-time care is covered) skilled nursing care or rehabilitative physical or speech therapy, to help her recover from a specific illness, injury, surgery, or acute condition. If, instead, she needs care because of a long-term condition or general frailty, Medicare will not cover it.
   • Medicare would cover at-home care only if and for as long as your mother is "confined to home" -- meaning she's unable to leave home without the assistance of another person or a medical device such as a wheelchair.
   • At-home care would be covered only while she is actively recovering, which means while her condition is improving. Once her condition has stabilized, Medicare coverage ends.

If your mother qualifies for coverage of at-home care, Medicare pays the full amount of the home 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). Your mother's condition and needs would be regularly evaluated by the agency and by Medicare itself to determine how long the care is medically needed.

Some Medicare Part C Medicare Advantage plans offer broader home care coverage than under original Medicare Part A and Part B. They may offer more services, and may have slightly easier qualifying rules, but they are not likely to provide home care for much longer than original Medicare, and certainly will not provide long-term maintenance care. Still, it's worth checking out what Medicare Advantage plans your mother might be eligible for, and what their home care rules are.