Changes Needed To Improve Access To Medicare Home Health Care
CMS could take several steps to restore beneficiaries access to the full scope of home health services under Medicare. An easy first step would be for CMS to launch a widespread educational campaign for providers, prescribers, contractors, adjudicators, and beneficiaries that explains the scope of services and qualifying criteria. Doing so would enhance knowledge about Medicares home care benefit and promote the shared goal of increasing beneficiaries access to community- and home-based care.
Types Of Home Care Medicare May Cover
Medicare may cover skilled home care services such as part-time or intermittent skilled nursing care, physical therapy, occupational therapy, speech-language pathology services, medical social services, and injectible osteoporosis drugs for women. Additionally, Medicare may cover part-time or intermittent home health aide services that is provided in conjunction with skilled services. A home health aide can assist with ADLs, complementing the skilled services. Notably, Original Medicare will not cover custodial or personal care , when this is the only care you need.
Coverage for custodial or personal care by Medicare Advantage plans will be discussed in the next section.
What Medicare Will Not Cover
Medicare will not pay for a number of services sometimes provided as part of home health care, including:
- drugs and biologicals administered at home
- personal care by part-time home health aides if this is the only care you need
- meals delivered to your home
- housekeeping services, or
- full-time nursing care.
If you require durable medical equipment, such as a special bed or wheelchair, as part of your home care, Medicare will pay only 80% of the costs.
For more information on Medicare coverage of home health care, read Medicare’s online publication Medicare and Home Health Care at .
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Whos Eligible For Home Health Services
If you have Original Medicare , you may be eligible if:2
Note: If you need full-time skilled nursing care for a long time, its unlikely that youll be eligible for home health care services.3
How Do I Find Medicare
Medicare.gov has a search and comparison tool to help you find certified home health agencies in your area that Medicare covers.
If you have coverage from a private Medicare Advantage plan, rather than original Medicare, you may have to use an agency that works with that Advantage plan. Talk with a Medicare Advantage plan representative about coverage details and requirements.
Before you start receiving care, the agency should let you know, both verbally and in writing, of services provided that Medicare wont cover and what you can expect to pay for them.
Keep in mind
You may be able to get additional caregiving support through local and state programs, which may provide services such as adult day care programs, equipment, meal delivery, respite care for caregivers and transportation. You can find out more about programs in your area through your Area Agency on Aging. Type your zip code or city and state into the U.S. Administration on Agings Eldercare Locator or call 800-677-1116, to find contact information for your local agency and other resources.
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What Is Home Health Care
Home health care is care that occurs within your home and includes nursing services like infusions, medication management, post-surgical procedures and physical therapy. Its not the same thing as home care, which typically consists of supportive care and assistance with activities of daily living .
Home health care is primarily intended to treat an acute illness or injury. The goal is for the patients health to improve enough that they regain independence and, if thats not possible, to manage symptoms to help them become as self-sufficient as they can, according to Medicare.gov.
Who Qualifies For Medicare Home Health Services
Medicare will cover a variety of in-home care if certain qualifications are met. To receive benefits under the home health care portion of Medicare, a senior needs to meet the following criteria:
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How To Pay For In
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 wont be covered by Medicare. This is where supplemental insurance comes in.
You may have already heard of Medigap insurance, which you purchase to help pay for all the medical costs that Medicare doesnt, like copayments, deductibles, and premiums. Its 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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Getting Home Health Services In Certain States
If you live in Massachusetts, Michigan, Florida, Illinois, or Texas, you may be eligible for a Medicare demonstration program. Under this program, you can request a pre-claim review to let you know early on whether Medicare coverage will likely cover your home health services.
If youâre a resident of one of these states, you might want to request a pre-claim review as soon as your doctor orders your home health care. This way, youâll know as soon as possible whether youâll be on the hook for any payments.
Ready to get started? Find a plan that fits your budget and covers your doctor and prescription medications now.
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What Home Health Services Are Available
Under Medicare Part A , along with Medicare Part B , there are a number of home health services available, including:
- Physical therapy
- Intermittent home health aide services for personal hands-on care
- Osteoporosis drugs .
The services will usually be coordinated by a home health care agency based on what your doctor has ordered for you.
Already Enrolled In Medicare
If you have Medicare, you can get information and services online. Find out how to .
If you are enrolled in Medicare Part A and you want to sign up for Part B, please complete form CMS-40B, Application for Enrollment in Medicare Part B . If you are applying for Medicare Part B due to a loss of employment or group health coverage, you will also need to complete form CMS-L564, Request for Employment Information.
You can use one of the following options to submit your enrollment request under the Special Enrollment Period:
Note: When completing the forms CMS-40B and CMS-L564:
- State I want Part B coverage to begin in the remarks section of the CMS-40B form or online application.
- If possible, your employer should complete Section B.
- If your employer is unable to complete Section B, please complete that portion as best as you can on their behalf and submit one of the following forms of secondary evidence:
- Income tax form that shows health insurance premiums paid.
- W-2s reflecting pre-tax medical contributions.
- Pay stubs that reflect health insurance premium deductions.
- Health insurance cards with a policy effective date.
- Explanations of benefits paid by the GHP or LGHP.
- Statements or receipts that reflect payment of health insurance premiums.
Some people with limited resources and income may also be able to get .
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What Parts Arent Covered
There are some aspects of in-home care that are convenient and even sometimes necessary to help sustain certain lifestyles, but they arent 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 cant leave the house.
- Custodial care when its 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 its 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 , lets discuss how you can qualify for in-home care.
Medicare Coverage For Home Health Care
Home health care is for someone who needs to receive skilled nursing care or rehab therapy in their own home. Without home health care, some individuals may not get the health care they need.
Medicare may cover the following services and items for those who qualify for the benefit.
- Part-time or intermittent skilled nursing care. Care must be provided by or under the supervision of a professional registered nurse.
- Physical, speech or occupational therapy.
- Durable medical equipment and supplies, such as a hospital bed for use at home.
Medicare beneficiaries who receive any part of the home care benefit may also be eligible to receive additional services, including:
- Medical social services, such as counseling or resources to help with the health condition
- A home health aide to help with activities of daily living like bathing and dressing
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Does Home Health Care With Medicare Have Out
If you have Original Medicare, you will not incur any out-of-pocket costs for home health care services approved by Medicare. This is because home health care does not attract copayments or deductibles.
However, if your in-home care requires medical equipment or supplies, these will be covered under your Medicare Part B benefits, but you need to pay 20% of the cost to be covered.
Remember that before the start of home health care, the Home Health Agency is required to give you a notice informing you of any services not covered by Medicare and any applicable out-of-pocket costs.
What Home Care Services Does Medicare Cover
The primary objective of Medicares home care program is to provide seniors with short-term skilled services in the comfort of their own homes as an alternative to recovering in a hospital or skilled nursing facility.
Skilled nursing services are those that must be provided by a qualified health professional, such as a Registered Nurse or a Licensed Practical Nurse .
Examples of these services include:
- Monitoring of a patients vital signs and overall health
- Wound care for a pressure ulcer or surgical incision
- Administration of intravenous drugs or nutrition therapy
- Catheter changes
- Patient and caregiver education
Skilled therapy services are those that must be provided by or under the supervision of a licensed physical therapist, occupational therapist or speech-language therapist.
- Physical therapy exercises typically focus on improving and restoring strength, balance and range of motion for optimal physical function.
- Occupational therapy assists in regaining the ability to independently engage in activities of daily living and adapting these tasks or the surrounding environment to improve functionality and accessibility.
- Speech-language therapy helps patients regain the ability to speak and communicate as well as overcome swallowing difficulties .
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Iii Medicare Coverage Of In
When it comes to Medicare coverage of in-home care, it is crucial to distinguish between standard home care and home health care. Medicare does not cover any standard in-home care because it is considered custodial care rather than health care. However, Medicare does cover eligible home health care services, which we explore in more detail below. Furthermore, in some cases, Medicare may actually cover custodial in-home care if delivered with home health care services from the same provider. Ultimately, seniors and their families should be aware that theyre unlikely to get help from Medicare paying for regular in-home care, but may have at least some home health care services covered by Medicare.
When Is Physical Occupational Or Speech Therapy Covered By Medicare
Physical therapy will be covered by Medicare when it will help the client regain strength or movement after an illness or injury. The same holds true for occupational therapy where the goal is to restore functionality, and for speech therapy to help patients relearn how to communicate.
The services will only be covered if they are expected to result in an improvement within a predictable period of time. Additionally, the frequency, duration, and number of services must be reasonable and provided by a qualified therapist. To be eligible for the services your condition must either:
- Be expected to improve,
- Require a maintenance program from a skilled therapist, or
- Require a skilled therapist for maintenance.
Professional therapists will restore or improve the clients ability to perform routine everyday tasks, speak or even walk following an illness or injury. They may also help prevent a condition from worsening and will only be covered if the services specifically, safely and effectively treat the clients condition.
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Home Health Care Eligibility Requirements
You may qualify for home health care if you meet the following qualifications.
- You require one of these in-home services:
- Part-time or intermittent skilled nursing care
- Physical, speech or occupational therapy
- Durable medical equipment for your use at home
You may be allowed to leave your home for medical appointments and occasional religious services or adult day care and still qualify for home health care.
Does Medicare Advantage Cover Home Health Care
Yes, Medicare Advantage plans cover home health care at the same level as Original Medicare. But Medicare Advantage plans may impose added rules, limitations and costs. Your plan may:
- Restrict your care to plan-contracted providers
- Require prior authorization or a referral from your family doctor on top of the mandatory Medicare certification
- Charge deductibles, copays or coinsurance
There’s only one home-care related benefit that sets Medicare Advantage apart from Original Medicare: meal delivery. But not every Medicare Advantage plan offers it, and the benefits vary by plan: For example, one plan provides meals only for patients with a specific medical diagnosis. As a result, we don’t recommend choosing Medicare Advantage based on this benefit alone.
In general, we found the Original Medicare home health benefit to be the better option for home care due to full coverage and fewer potential roadblocks to receiving care. Medicare Advantage plans may limit provider choice, assess fees or require referrals and preauthorizations for care. Medicare Advantage plans add very few extras for home health care or durable medical equipment when needed as part of home care.
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Finding A Medicare Certified Home Health Agency
Medicare will only pay for your home health care if you choose a home health agency that is Medicare certified to ensure they meet federal health requirements.
Before you choose a health agency, make sure that:
- The health agency is Medicare-certified
- It offers the specific health care services that you require
- It is recommended by your doctor or hospital
Do Medicare Supplement Insurance Plans Cover Nursing Home Costs
Some Medicare Supplement insurance plans include increased coverage in skilled nursing facilities . Medicare Supplement insurance plans may cover your out-of-pocket costs for doctor visits and other medical services covered under Part A and Part B while you are a nursing home resident.
You can start comparing Medicare Advantage plans right away just enter your zip code in the box on this page.
New To Medicare?
Becoming eligible for Medicare can be daunting. But don’t worry, we’re here to help you understand Medicare in 15 minutes or less.
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Does Medicare Pay For Nursing Home Care
If you have had a qualifying inpatient hospital stay and your doctor orders an additional period of treatment in a skilled nursing facility, Medicare Part A generally covers allowable expenses. Your Part A nursing home benefit usually covers:
- A semi-private room
- Medical equipment and devices you use during your hospital stay
- Ambulance transportation to and from the facility
There are costs for a covered stay in a skilled nursing facility . In 2019, you pay no coinsurance for days 1 through 20, $170.50 per day for days 21 through 100, and all nursing home costs for your care after the 100th day.
Medicare does not, however, pay any nursing home costs for long-term care or custodial care. If you need unskilled care for activities of daily living, care for an extended period of time, or care that is not reasonably expected to improve your condition within a limited timeframe, Medicare will not cover it.