Will Medicaid or Medicare Provide Coverage for Long-Term In-Home Care?

The short answer is that Medicare provides in-home care only in very limited circumstances for a short time, while Medicaid can provide long-term in-home care. Here are the terms under which both programs provide in-home care.

Medicare coverage: Medicare coverage for in-home care is extremely limited. In order to qualify for Medicare-covered in-home care under either Medicare Part A or Medicare Part B, a person must be confined to home and have a medical need for skilled nursing care or rehabilitative physical or speech therapy. The care must be prescribed by a doctor, to help the patient recover from a specific illness, injury, or acute condition. If Medicare approves the skilled nursing or rehabilitation care, it covers only part-time care provided by a Medicare-certified home care agency. It does not cover care provided by family members or individual paid caregivers. The exact amount of in-home care Medicare will cover for any particular patient is determined by Medicare based on the opinion of the patient's doctor and the home care agency that provides the care.

Medicare coverage for in-home care continues only as long as the patient is recovering. Once a patient's condition becomes stable, Medicare no longer covers care at home. So if what a patient needs is nonmedical assistance with the activities of daily living -- because of general frailty or because of an injury, illness, or medical procedure from which he or she has recovered as far as possible -- Medicare will not cover it. (However, if a patient is receiving Medicare-covered skilled nursing or therapy at home, Medicare can cover a limited amount of personal care as well.)

Medicaid coverage: Medicaid coverage for in-home care can be much broader than Medicare's. Medicaid rules vary from state to state, so the exact extent of Medicaid in-home care coverage depends on the extent of coverage offered by a state's particular Medicaid program, as well as on the patient's needs. But in general, if someone qualifies financially (with very low income and few assets other than the patient's home), Medicaid can provide regular, part-time in-home care if the patient needs assistance with medical care or the activities of daily living. To qualify, a patient might need a doctor's certification that a medical condition creates a need for care.

If Medicaid covers in-home care, it can pay for an aide from a Medicaid-certified home care agency to visit the Medicaid beneficiary several times a week, to help with both medical and nonmedical care tasks. The frequency and length of the home care visits, and the kinds of care provided, would be determined by the patient's condition and needs, and by the specific rules of the state's Medicaid program. In some states, Medicaid can pay a qualified beneficiary directly for necessary in-home care, and the beneficiary can then turn around and pay anyone he or she wants to provide that care -- including family members.

To find out more about Medicaid eligibility and in-home care coverage rules in a particular state, go online to any search engine and enter Medicaid and the name of the state. Or call the Eldercare Locator toll-free at (800) 677-1116 and ask for contact information for the state's Medicaid program.