Sometimes it doesn’t make sense to receive health services in a hospital or other health care setting. Some seniors benefit greatly from home health care, which covers a list of health and social services in your home environment for the purpose of treating illness or injury. But health care without insurance coverage is expensive; many seniors may wonder if home health care is covered by Medicare. The answer is yes and no. Medicare does have a home health benefit that covers certain intermittent* skilled health services under either Medicare Part A or Medicare Part B.
In-Home Care Covered by Medicare
The following in-home services are covered by Medicare:
Part-time or intermittent skilled nursing care**
Intermittent skilled therapy care including physical, speech and occupational therapy
Part-time or intermittent care from a home health aide (personal hands-on care)
Medical social services including an assessment of the social and emotional factors connected to the patient's illness and care
Medical supplies for use at home, durable medical equipment such as hospital beds, and injectable osteoporosis drugs for women
Most seniors work with a home health care agency who helps coordinate the health services ordered by their doctors.
*Medicare defines intermittent care as when care is needed at least once every 60 days, at most once a day for up to three weeks. If you still require care after 60 days, the time frame can be extended but the care plan must be predictable and have an end date.
**For Medicare’s purposes, skilled nursing care is defined as health care that is only provided by a skilled professional or under a professional’s supervision.
What will I pay toward in-home care services covered by Medicare?
Seniors enrolled in Original Medicare can generally expect to pay $0 for home health care services and 20% of the Medicare-approved amount for durable medical equipment. It is always best to discuss costs up-front with your doctor or health care provider.
Any out-of-pocket costs should not come as a shock. Before care begins, the home health agency you are working with should tell you how much Medicare will cover. They should also list any items or services they are planning to provide for you that will not be covered by Medicare and how much you will be billed for them. The home health agency should give you a notice called the “Advance Beneficiary Notice” (ABN) before providing any services or supplies to you that Medicare doesn't cover.
In-home care that Medicare does not pay for
Medicare won’t pay for the following in-home care services:
Occupational therapy for help improving daily activities such as getting in and out of bed without assistance or personal care such as help using the bathroom, does not qualify for home health care coverage if this is the only care needed. There are a couple of exceptions to this: Kupuna who qualify for home health care for other approved reasons can also get occupational therapy. And, after other home health care needs are met, seniors can keep receiving Medicare-covered occupational therapy under the home health benefit, if needed.
“Homemaker services” such as cleaning, help with laundry and grocery shopping if this is the only care needed.
Home-meal delivery services.
Medicare covers home health services for the following groups of people
1. You are homebound and your doctor has signed a home health certification confirming that you are homebound and need intermittent skilled care in your home because it is extremely difficult for you to leave your home and when you do, you require help. The certification must state that your doctor has approved a plan of care for you and that you have met the face-to-face meeting requirement. The certification of your home health plan should be reviewed and recertified every 60 days. Note: during the Covid-19 pandemic, certification has not been required.
2. You are scheduled for an in-person meeting with a physician in an office or hospital setting within the 90 days before you are scheduled to start home health care, or the 30 days after the first day you receive home care.
3. You receive home care from a Medicare-certified home health agency (HHA).
Do Medicare Advantage Plans offer home health services coverage?
There are Medicare Advantage Plans that cover non-skilled in-home care such as help with bathing and occupational therapy. If you are looking for coverage of in-home care services that are not covered by Original Medicare, please contact your trusted Medicare insurance agent to discuss your coverage options.
If you meet all the requirements outlined above, Medicare should be paying for the skilled care and/or home health aide home services that you require. The Medicare agents at PBC can help you navigate the in-home health services you qualify for and discuss Medicare supplement options that could boost your coverage.
Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. Because we represent all the major Medicare Advantage and supplement plans in Hawaii, we are able to offer unbiased advice; all at no cost to our clients.
At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.