If you or a loved one has recently returned home from the hospital or needs home health care or physical therapy for an illness or injury, you might be wondering if Medicare will foot the bill.
The short answer is yes – both Medicare Part A and Part B cover in-home care in different situations. This article outlines what’s covered, the eligibility requirements, and what Medicare doesn’t pay for.
What Is Home Health Care?
Medicare.gov defines home health care as medical treatments and health care services supplied in the patient’s home to address an illness or injury. It is considered less expensive than getting treatment and therapy services at a skilled nursing facility without sacrificing the quality of care.
Medicare home health coverage includes medical treatment, durable medical equipment, and certain medical supplies.
What In-Home Care Does Medicare Pay For?
Home health care coverage is available under Medicare Parts A and B.
Medicare Part A, referred to as “hospital insurance,” is known for paying for inpatient care in hospitals and skilled nursing facilities. Medicare Part A also provides for home health care if specific eligibility requirements are met.
While Medicare Part A provides nurse care, Medicare Part B functions more like traditional medical insurance, covering outpatient services and durable medical equipment (DME). The list of DME items covered by Medicare is extensive, and it includes everything from wheelchairs and walkers to hospital beds, commode chairs, and oxygen equipment.
Depending on your circumstances, either Medicare Part A, Part B, or both will pay for skilled nursing services. Generally speaking, Medicare Part A applies when you require care after a hospital stay. Part B Medicare benefits kick in when you need in-home care, but there was no previous stay in a hospital.
Eligibility Requirements for Home Health Services
A Medicare beneficiary must meet specific eligibility requirements for Medicare to pay for daily skilled nursing care, including:
- The home health services must be ordered or approved by a medical professional or authorized practitioner.
- The Medicare beneficiary must be homebound, meaning that the person cannot leave home without “considerable effort.” This criterion is met if it can be shown that the person needs assistance, either from another person or a medical device such as a walker or wheelchair.
Occasional outings are permissible for church or religious services, and brief excursions for fresh air. Medicare beneficiaries attending adult daycare retain eligibility for home health care services.
- Home care coverage extends only as far as intermittent skilled nursing care. This means that the home health care coverage is limited to 28 or fewer hours per week (up to eight hours per day). Physical therapy, speech therapy, occupational therapy, and other skilled therapy services also fall under the umbrella of intermittent care.
These coverage limits for the number of hours of care can be extended to up to 35 hours per week, subject to review.
- The agency providing the care must be a certified Medicare home health care agency.
- Coverage for home health agency services is still available even if the Medicare beneficiary has a family caregiver or another caregiver providing personal care.
If you need services that are not covered by the home health agency, the agency must provide you with an Advance Beneficiary Notice of Noncoverage. If you believe that coverage is warranted, you can file an appeal.
What Home Health Services are Covered by Medicare?
The list of eligible home health services includes:
- Part-time nursing care
- Part-time care from home health aides
- Physical therapy, occupational therapy, and speech therapy services
- Medical social services
- Medical supplies and equipment
Medicare Home Care Myth Busting
A persistent myth about the Medicare home health benefit is that coverage is only available on a short-term basis for acute conditions. Perhaps the term “intermittent” has been confused with short-term because the reality is that Medicare-covered home health care services can extend indefinitely, provided that the other coverage requirements are met.
The perpetuation of this myth can be detrimental to Medicare recipients because it discourages them from seeking the skilled nursing help and home health aide services they need.
Some beneficiaries are also misled about the number of hours of home health care services they can receive or that they aren’t eligible for Medicare home health benefits because they aren’t sufficiently homebound.
The result of this confusion can lead families to pay out-of-pocket for nursing services that should have been part of Medicare coverage. Social and emotional concerns about the elderly population and declining health are often swept under the rug in the name of budgetary constraints. A Medicare insurance expert can help beneficiaries and their families better understand more about Medicare coverage criteria for these services.
Important Updates to the Medicare Payment System
As of 2020, a new system took effect called the “Patient Driven Groupings Model,” or PDGM for short. The system updates the financial model for different timeframes of home health care. According to CMS, the system more accurately codes a patient’s reason for needing home health care based on increments of 30 days, making classifications more “meaningful.”
However, Medicare advocacy groups caution that patients with chronic or longer-term home health care needs will be denied access to free or affordable coverage, adversely affecting health outcomes.
Home Health Care vs. Home Care
Home health care and home care are two different categories of medical care, and Medicare Parts A and B cover home health care but not home care. Home care is considered “non-skilled personal care” that helps a patient with tasks associated with daily living, such as bathing, cooking, and cleaning.
In some instances, these tasks are covered on a limited basis under physician orders. However, to ensure that personal care services are covered, beneficiaries should enroll in Medicare Advantage Plans. Medicare Advantage, also called Medicare Part C, is an alternative to traditional Medicare, and it provides coverage for care from home health agencies.
Conclusion
Medicare can get complicated, but a Medicare Advantage advisor can assist you in getting a plan that covers the medical services you need. If you are interested in Medicare, sign up at 65 years old to avoid paying penalties or delaying necessary coverage.