When Does Medicare Pay for Home Health Care?

Posted: 11/21/2018 3:19 AM by Interim HealthCare

If you or your loved one needs home health care or senior care, you’re no doubt wondering one thing: Is it covered by Medicare?

Since its introduction in 1965, Medicare, the federal health insurance program for people 65 and over, has paid many of the medical bills for older Americans. But, as Medicare recipients and their families are often surprised to discover, it doesn’t cover everything. One area that can be particularly tricky is home care.

What it doesn’t cover

When it comes to home care, it’s easiest to start with what Medicare doesn’t cover. It doesn’t cover full-time in-home services of any kind. And it doesn’t cover a part-time or intermittent home aide (this kind of help is often called non-medical, private duty or personal care service) unless one is necessary for medical reasons, and then only in conjunction with skilled nursing care and/or physical, occupational or speech therapy.

If all you need is non-medical home care — help with everyday tasks, such as bathing and dressing and meal preparation — Medicare won’t cover it.

What it does cover

Medicare covers some part-time home health care services that are deemed medically necessary. For example, if you are eligible for Medicare and a doctor decides you need part-time or intermittent skilled nursing care at home due to a disease or illness or after an injury, surgery, heart attack or stroke, Medicare should pick up some of the bill. It also covers some physical, occupational and speech therapy.

By part-time or intermittent skilled nursing care, Medicare generally means care that is provided in the home less than seven days a week or daily for less than eight hours a day and for no more than 21 days. If you need more than that, you won’t qualify for coverage.

If you’re receiving skilled in-home care prescribed by a doctor, you may also qualify for part-time non-medical (home aide) services for a certain length of time. Medicare recipients are eligible for a combined total of up to eight hours per day and 28 hours per week (35 in some cases) of skilled nursing care and home aide services.

Medicare defines the limits on therapy services more broadly, saying that their amount, frequency, and duration must be “reasonable” given the patient’s needs.

The doctor must create a plan of care, review it at least once every 60 days and certify that the services are necessary. He or she must also certify that the recipient is homebound, although Medicare recipients can leave their homes for medical reasons or to attend adult daycare, for example. The services must be provided by a Medicare-certified home health agency.

All of these rules apply to what’s known as traditional or original Medicare, the program run by the government. If a Medicare recipient is enrolled in a Medicare Advantage plan (these are offered by private insurance companies approved by Medicare), some details may differ, so it’s important to check with the insurer.

If you’re not sure what’s covered and what isn’t in your situation, talk to your home health care agency. It should be able to explain which of its services are covered by Medicare and which the recipient or family members will have to pay for out of pocket.

Other ways to pay

If the patient has other insurance, such as a long-term care policy or retiree health insurance from a former employer, it may pay some of the costs, both medical and non-medical. If the patient has a Medicare supplement, or Medigap (private insurance that supplements original Medicare) in addition to Medicare, it may cover some of the co-pays or deductibles Medicare requires.

Medicaid, the joint federal and state program for low-income and needy children and adults, also covers medically related home health care services. In addition, it provides for some personal or custodial care that Medicare doesn’t, although that varies by state. Bear in mind that Medicaid has strict eligibility requirements, including limits on the person’s income and assets, so not everyone qualifies.

For more information on what services Medicare covers, visit Medicare at www.medicare.gov/coverage/home-health-services or visit the State Health Insurance Assistance Programs (SHIPs) at www.shiptacenter.org. SHIPs provide free insurance counseling and assistance to Medicare beneficiaries and their families.

Contributed by Greg Daugherty. A former senior editor with Money magazine, Daugherty often writes about the financial aspects of health care.