Medicare In-Home Care Coverage
Updated for December, 2021
Medicare covers a wide range of services under parts A and B of the plan, including hospital stays and visits to your primary care physician. Many of these services require you to leave your home to get diagnosed and/or treated, but what if it’s difficult or close to impossible to go anywhere? Or, what if your condition could worsen by leaving your home? This is where in-home care gets involved.
Home health services are covered by Medicare to provide a convenient and safe way for elderly people to get treated without having to leave the comfort of their homes. Now, before we discuss exactly what Medicare covers when it comes to in-home care, let’s discuss what home health care is.
What Is In-Home Care?
In-home care (also known as “home health care”) is a service covered by Medicare that allows skilled workers and therapists to enter your home and provide the services necessary to help you get better.
In-home care is especially helpful for immobile people and patients who have a difficult time leaving the house several times a week to go therapy or a hospital for treatment.
Home health care can include but is not limited to:
- Skilled nursing care: This refers to care that can only done by nurses with proper licensing. This care includes dressing wounds, rehabilitation deemed necessary by a doctor, and changing feeding tubes and other tube structures (catheters, IVs, etc.).
- Physical therapy: This is therapy that can be done at the home to help rehabilitate or treat conditions such as arthritis, broken bones, or other physical injuries.
- Occupational therapy: The AOTA says this therapy “helps people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities.” These activities include holding writing utensils, coping with now having to use a wheelchair, and other simple activities of daily living like grooming and feeding yourself.
- Speech therapy: Speech-language pathologists helps diagnose, assess, and re-develop speech in people who need it. For instance, a speech-language pathologist could be used after someone suffers a stroke and needs to learn how to speak again.
- Nutrition care: These workers help ensure you’re eating properly and living in the proper conditions. This isn’t a medical service, but it can be covered by Medicare if it’s in your area and your doctor deems that you need it.
- Safety services: This service features workers who specialize in transportation. They make sure that you’re living in a safe environment and can get from point A to point B safely if you can leave your house with assistance and it won’t worsen your condition.
In-home care plans are developed by a doctor and administered by skilled workers included registered nurses, speech language pathologists, occupational therapists, and social workers. Plans developed by doctors, which can include any of the aforementioned in-home care services, are evaluated every 60 days, or sooner if an intense program requires that level of attention.
Close attention must be paid to these in-home plans because Medicare coverage relies on it. According to the Medicare website, “your condition must be expected to improve in a reasonable and generally predictable period of time.”
Medicare covers the other 80 percent of the costs under your Part B plan.
What Parts Of In-Home Care Are Covered?
In-home care can cover a wide range of services, but they’re not all covered by Medicare. According to the Medicare site, the in-home care services covered by parts A and B include:
- Part-time or occasional (intermittent) skilled nursing care
- Part-time or occasional health aide care (This is different from nursing care because an aide’s
role is to help you get dressed, bathed, buy groceries, and other vital wellness necessities that help you live)
- Physical therapy
- Occupational therapy
- Speech-language therapy
- Medical social services, such as workers who help make sure you’re being billed for the right things and not being abused or taken advantage of by other people on your case
- Durable medical equipment needed to treat your condition
All of these services are covered under parts A and B of Medicare. The prescriptions you receive as part of your treatment are covered by Medicare, too, whether it’s under parts A and B or under your Part D prescription plan.
The services themselves will cost you zero dollars out of pocket (aside from whatever deductibles and copayments you pay for your Medicare plan). The only extra cost you’ll have for home health services is 20 percent of whatever durable medical equipment is needed for your services. Medicare covers the other 80 percent of the costs under your Part B plan.
What Parts Aren’t Covered?
There are some aspects of in-home care that are convenient and even sometimes necessary to help sustain certain lifestyles, but they aren’t all covered by Medicare. These services include:
- 24-hour skilled nursing care: If you or a loved one needs this, you may be better off in a skilled nursing home facility, which Medicare does cover.
- Meals delivered to your home: While there may be aides who help do this in your home, you will not be reimbursed for having meals brought to you because you can’t leave the house.
- Custodial care when it’s the only service you need: Custodial care refers to any non-medical help you need, such as with bathing or getting dressed. However, this type of care could be included in your plan if your doctor deems that it’s necessary to improve your condition.
- Homemaker services: This includes activities such as shopping, cleaning, and laundry, as described by the Medicare website. This also could be covered if they are related to your home health plan prescribed by your doctor.
So now that we know what Medicare covers (and doesn’t), let’s discuss how you can qualify for in-home care.
You can’t simply decide that you prefer your nursing care and other therapy needs in your home. You must meet the qualifications for in-home care.
How To Get Approved For In-Home Care
There are a handful of steps and qualifications you need to meet to have your in-home care covered by Medicare. It starts with the type of help your doctor says you or your loved one needs and includes other aspects of care.
You can’t simply decide that you prefer your nursing care and other therapy needs in your home. You must meet the qualifications for in-home care, and they include the following:
You must be under the care of a doctor:
The primary step in getting approved for in-home care is that you and the nursing plan must be under the care of a Medicare-approved doctor. This doesn’t mean that the doctor will be at every visit. A home health nurse specialist will administer your plan, which your will “create and regularly review.”
This is when you’re unable to leave your house for treatment. Homebound patients require assistance from a person or piece of durable medical equipment (DME) such as a walker or wheelchair to get around the home or to get to services outside the home. Immobile people are considered homebound as well. A doctor can deem that you’re homebound if he or she believes that your illness or condition could get worse if you left the home.
You doctor certifies that you need home care:
This is the most important part of receiving approval for in-home care. Your supervising Medicare-approved doctor basically needs to prescribe you in-home care. According to the Medicare site, your doctor must say that you need: intermittent skilled nursing care (which means you don’t need the care every hour of the day) or some form of therapy, including physical therapy, occupational therapy, and speech-language therapy. If your doctor prescribes some form of in-home therapy, the plans must be “expected to improve in a reasonable and generally predictable period of time.” The Medicare site also says that you need “skilled therapists” to implement and maintain your therapy plans.
You don’t need round-the-clock care:
Medicare doesn’t cover 24-hour in-home care. If you need this level of care, your doctor may recommend that you or a loved one enter a skilled nursing home facility, which is covered by Medicare. You will only qualify for in-home care if part-time or intermittent skilled nursing care is needed, as mentioned before.
Your in-home care comes from an approved home health agency:
The only way Medicare will cover your home health costs is if you receive your care from a Medicare-approved home health agency. Your doctor may have recommendations for agencies that are Medicare-approved that he or she trusts with their patients.
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Cashing In On In-Home Care
Once you qualify for in-home care, it’s time to find the right agency who will provide you or your loved one services. The company you receive your services from is up to you, but they must be approved by Medicare in order for their services to be covered.
Not all in-home care companies provide the same services. Some may specialize in physical therapy, while others offer every service you need. You may have to contact multiple companies in order to get all the services you need.
Medicare provides a checklist of questions you can follow when looking into choosing a home health agency for your services. Some of the questions include:
- Is the agency Medicare-certified?
- Does the agency offer all the services I need, including physical and occupational therapy?
- Did my doctor recommend them/does he or she know about them?
- Do they have staff that can assist me in an emergency or time of need?
- Does the agency fit my personal needs, like a language barrier or physical needs?
- Are there patient and family reviews of the agency and their good service?
View the whole checklist here.
If you answered “no” to any of these questions, you should reconsider receiving services from that agency. You will want to avoid needing to find a second agency to administer certain therapies or needing to pay for services provided by a company that isn’t Medicare-certified.
You can get started with researching and comparing home health agencies on the Medicare site. They have a comprehensive database that allows you to look up agencies in your area and compare their reviews and star ratings (administered by Medicare), which are based on how well they perform, their price points, and customer reviews.
How To Pay for In-Home Care Not Covered By Medicare
There may be times when not every part of your in-home care is covered. We already know 20 percent of the durable medical equipment needed to treat you is your responsibility, but there are other services like custodial care or extra round-the-clock care that won’t be covered by Medicare. This is where supplemental insurance (Medigap) comes in.
You may have already heard of Medigap insurance, which you purchase to help pay for all the medical costs that Medicare doesn’t, like copayments, deductibles, and premiums. It’s also a useful source to have when it comes to in-home care. Supplemental insurance could help cover the costs that you may accrue, like personal care, meals delivered to your home, and the remaining costs of your DME.
If you have any questions regarding your in-home care and what is covered by Medicare, contact your local Social Security office.
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