Medicare will cover home health care services and may cover nonmedical home care services in some cases. The primary objective of Medicare home health care coverage is to provide seniors with short-term skilled services in the comfort of their own homes as an alternative to receiving services in a hospital or skilled nursing facility.
There’s an important distinction between medically necessary home health care and nonmedical personal care services. Understanding the difference between these two levels of care is key to determining who’s eligible for Medicare-covered in-home services.
Read: Home Care vs. Home Health Care: What’s the Difference?
Who can receive home care covered by Medicare?
An older adult must have coverage through Medicare Part A (hospital insurance) and/or Medicare Part B (medical insurance) and meet the following criteria as set forth by Medicare.gov:
- Eligible recipients must be under the care of a doctor. The doctor must prescribe a plan of care that involves medically necessary services for the treatment or maintenance of a health condition.
- Eligible recipients must be certified by a doctor as homebound. This means it requires a considerable and taxing effort to leave the home because of reliance on a mobility aid (e.g., cane, wheelchair, or walker), special transportation, or the assistance of another person to do so. An individual can qualify even if they're able to leave home for medical treatments, adult day care, and short, infrequent nonmedical outings, such as religious services and family gatherings.
- Eligible recipients must have a doctor’s certification of need for at least one of the following services:
- Intermittent skilled nursing care
- Skilled therapy services
- Services must be provided by a Medicare-certified home health care agency.
What home health care services are covered by Medicare?
Two general categories of services are covered by the Medicare home health care benefit: skilled nursing services and skilled therapy services.
Skilled nursing services must be provided by a qualified health care professional, such as a registered nurse (RN) or a licensed practical nurse (LPN).
Examples of these services include:
- Monitoring of a patient’s vital signs and overall health
- Wound care for a pressure ulcer or surgical incision
- Administration of intravenous drugs or nutrition therapy
- Injections
- Catheter changes
- Patient and caregiver education
Skilled therapy services must be provided by or under the supervision of a licensed therapist. These services must be necessary to improve the patient’s condition in a reasonable and somewhat predictable period of time.
Types of therapy services include:
- Physical therapy, which focuses on improving and restoring strength, balance, and range of motion for optimal physical function.
- Occupational therapy, which assists patients in regaining the ability to independently engage in activities of daily living (ADLs). This may involve adapting daily tasks or the surrounding environment to improve functionality and accessibility.
- Speech-language therapy, which helps patients regain the ability to speak and communicate as well as overcome swallowing difficulties (dysphagia).
It’s important to note that the above services will only be covered if they're deemed specific and effective treatments or maintenance methods for a patient’s condition.
Will Medicare pay for home health care provided by a family member?
No, Medicare only pays for medically necessary home health care that’s ordered by a doctor and provided by a certified home health care agency. However, Medicaid may offer ways to pay a family member who cares for a loved one at home.
Read: How to Get Paid as a Caregiver for Elderly Parents
Does Medicare pay for home health care for dementia?
Yes, Medicare will pay for intermittent, medically necessary home health care services in accordance with the requirements listed above. However, it's important to note that Medicare doesn't cover the long-term personal care and supervision that a senior with dementia will eventually need to continue living at home safely. These types of nonmedical home care services are typically paid for out of pocket or using other sources of coverage.
Read: How Much Does In-Home Dementia Care Cost?
How long will Medicare pay for home health care?
Medicare will pay for part-time or “intermittent” home health care. This means services that are needed “less than seven days per week or less than eight hours per day over a period of three weeks or less.” This care is intended to be temporary, so a patient’s doctor must recertify their plan of care every 60 days if additional care is needed.
Medicare standards will determine the frequency and duration of the care a senior receives. Once a patient’s needs exceed intermittent care, Medicare is no longer a payment option. Medicare views home health care services as a way to prevent or delay placement in an assisted living community or skilled nursing facility, not completely replace them.
Does Medicare cover in-home care?
Medicare won’t pay for nonmedical in-home care if that’s the only service needed. Personal home care services (assistance with activities of daily living) or homemaker services (e.g., light housekeeping, laundry, meal preparation) will only be covered if they’re part of the home health services detailed in a patient’s care plan. Medicare doesn’t cover around-the-clock home care of any kind or meals delivered to the home.
Does Medicare advantage cover home health care?
Yes, Medicare advantage plans cover home health care services. These plans are offered by Medicare-approved private health insurance companies. At a minimum, advantage plans must provide the exact same coverage that Medicare Parts A and B provide. However, they may impose some additional restrictions and costs. For example, most advantage plans require seniors to use health care providers in the plan’s network.
To receive home health care coverage through a Medicare advantage plan, one may need to do the following:
- Receive a referral from a doctor before receiving care
- Use a home health care agency that operates in the plan’s network
- Pay a copayment
Read: How Do Medicare Advantage Plans Work?
How much does Medicare-covered home health care cost?
With original Medicare coverage (Part A and/or Part B), eligible seniors pay nothing for home health care services that are ordered by a doctor and provided by a Medicare-certified home health agency. However, any additional services provided outside of a patient’s approved care plan won’t be covered and must be paid for out of pocket.
Before services begin, the home health agency should provide an itemized receipt or plan of care that identifies what’s eligible for Medicare coverage and what isn’t. The agency should also provide a written “Advance Beneficiary Notice” (ABN) detailing any services and durable medical equipment that Medicare won’t pay for as well as any costs the patient is responsible for.
Support for families navigating Medicare and home care
In some cases, Medicare may be a good resource to help families cover some home care costs, but there are several eligibility restrictions and care limitations. Fortunately, families have numerous options to choose from when it comes to paying for in-home care.
Searching for the right home care provider that fits your loved one’s needs and budget can be complicated. But our Care Advisors can help simplify your search. Additionally, the AgingCare forum offers the opportunity to connect with other family caregivers for answers, advice, and support.
Reviewed by Certified Elder Law Attorney Letha McDowell.
Sources:
Home health services (https://www.medicare.gov/coverage/home-health-services)
Medicare Advantage and home health (https://www.medicareinteractive.org/get-answers/medicare-covered-services/home-health-services/medicare-advantage-and-home-health)