Posted on March 21, 2022 by Austin Lang
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Posted on March 21, 2022 by Austin Lang
For many seniors with chronic conditions, making the trek to a skilled nursing facility can be difficult and uncomfortable. Home health care services are designed to ease this burden, allowing you to receive care in the comfort of your own home. But does Medicare cover home health care?
The Medicare Home Care benefit is explicitly designed to be an alternative to a stay in a hospital or skilled nursing facility, allowing you to maintain more independence. However, you need to meet specific eligibility requirements before Medicare pays for anything.
First, you must be enrolled in Medicare Part A or B, or the equivalent. Home care falls in a gray area between Parts A and B, so you only need to be enrolled in one or the other to qualify. However, if you need home health services, you will likely also need hospital and skilled nursing services (covered under Part A), and approval from a physician (covered under Part B), so having both parts is usually a good idea.
This article focuses on the home care benefits as outlined under Original Medicare. Members of Medicare Advantage plans have the same basic coverage by law but might have additional benefits or more relaxed eligibility requirements, depending on the specific plan.
You must also be under a doctor’s care, who will establish and review a plan of care. This plan of care should include at least one of the following services:
Your doctor must also certify that you are homebound. Being homebound means you have difficulty leaving your home without help due to an illness or injury, or leaving your home isn’t recommended due to a condition. Those reliant on mobility aids (like wheelchairs or walkers) or those reliant on special medical equipment that is difficult to transport also qualify as homebound.
Note that being homebound does not mean you can never leave your home: you can have short, infrequent absences for non-medical reasons, like walking around the block or visiting the barber. You can even travel for certain unique or infrequent occasions, like family reunions or graduations. If you are attending adult day care, you still qualify as homebound.
Once you meet these requirements, your doctor will refer you to a Medicare-certified home health agency, which will coordinate your care and connect you with home health services.
Once you qualify, your Medicare-certified home health agency will connect you to the following services:
Skilled nursing care is defined as services offered by a medical professional: typically a registered nurse or nurse practitioner. This includes changing complex wound dressings, inserting catheters, performing blood transfusions, monitoring injected or intravenous medications, and monitoring vitals.
Original Medicare only covers intermittent (part-time) nursing care. This means the frequency of your treatment must fall under one of two categories:
Either way, this recurring need is limited to periods of 21 days or less. In most cases, you won’t need skilled nursing care very often, as skilled nursing care is meant to replace the care you would receive at a hospital. If you need more regular care, you may need to pay for full-time home care or care at a skilled nursing facility.
A home health aide is a healthcare paraprofessional: a step below a nurse but still skilled in their own right. While nurses handle medical procedures you’d usually have performed at a hospital, a home health aide is focused on maintaining the quality of life. They can help with things like preparing meals, hygiene, daily activities, and monitoring your health on a daily basis.
Like skilled nursing care, these services are only available intermittently. In addition, Original Medicare will only cover these services if you are also receiving skilled nursing care. If you need a full-time caregiver, or if health aide services are the only services you need, you’ll need another option.
Physical and occupational therapy falls under the umbrella of skilled nursing care but is two of the most important aspects of home care.
Most readers are probably familiar with physical therapy: it’s a therapy designed to restore and maintain your ability to move and function in day-to-day life. PT can also help prevent physical decline, allowing you to preserve your range of motion well into old age.
Occupational therapy focuses more on your recovery and maintaining your ability to do meaningful activities. It tends to focus more on mental and cognitive health than PT. Both types of therapy work together to help you restore and maintain your independence.
Speech-Language Pathology is related to occupational therapy, focusing on communication, cognition, and swallowing. Commonly assumed to be related to treating speech disorders like stuttering, this field is much broader and can help with everything from vocal damage to cognitive disorders resulting from a stroke or dementia.
If you need specific devices as part of your home care, Medicare will cover some of the cost. This includes wheelchairs, patient lifts, physical therapy equipment, and any other devices you might need.
Other services, like injectable medication for osteoporosis, may also be covered. Consult with your doctor and home health agency for more details.
Under Original Medicare, you pay nothing for in home care and 20 percent of the Medicare-approved cost for durable medical equipment. However, it won’t cover long-term care or health aide services that aren’t accompanied by skilled nursing care.
Medicare Advantage works a bit differently, however. As these plans are offered privately, they often have relaxed requirements for eligibility and may offer benefits like home health aide services, meal delivery, and transportation. They may also cover 100 percent of the copay for durable medical equipment. Check with your plan provider to learn more.
Telehealth is a related, yet distinct benefit from in home care, referring to any medical service received remotely. Usually, this is done through a dedicated app or website, though restrictions were relaxed during the height of the COVID-19 pandemic to allow services over Zoom, Skype, and similar services.
Originally, telehealth was offered only to seniors living in remote areas. However, CMS has temporarily expanded coverage to all Medicare beneficiaries. It is currently unknown if or when this expanded coverage will be rescinded. However, many Medicare Advantage plans offer expanded telehealth services through partnerships with providers like Teladoc. If you need home health services or want to review your Medicare benefits, enter your zip code above or call (800) 950-0608 to speak with a licensed insurance agent today.