Home Health Benefit Widely Misunderstood
Medicare rules state that if a beneficiary is considered homebound and requires skilled nursing, physical therapy, or speech language pathology services, he or she also can qualify for dependent services, including home health aides. Medicare law authorizes up to 28 to 35 hours per week of home health aide and nursing services combined, as well as therapies and medical social services. If a person continues to meet these criteria, there is no limit to the duration of services. In other words, contrary to what people are often told by providers, Medicare Advantage plans, 1-800-MEDICARE, and even the Centers for Medicare and Medicaid Services , home health coverage is not just a short-termbenefit to help people recover from an acute event.
The Center for Medicare Advocacy hears regularly from people who meet Medicare coverage criteria but are unable to access home health benefits or denied the appropriate amount of care. The legal standards that define who can obtain coverage and what services are available are often narrowly construed and misunderstood by providers and Medicare adjudicators.1 This is increasingly true for home health aide services, although help with activities of daily living is often what older and disabled people need to remain healthy and safe at home.
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:
o Part-time or intermittent skilled nursing care
o Physical, speech or occupational therapy
o Durable medical equipment for your use at home
- You are under the care of a doctor and receive your home health services under a plan of care reviewed regularly by a doctor.
- The home health care provider is Medicare-approved.
- You are homebound, and your doctor certifies that you are homebound. Homebound means:
o You have a health condition that makes it difficult and possibly harmful if you try to leave the home.
o Leaving your home takes a considerable and taxing effort.
o You need special transportation, the help of another person, or a wheelchair, cane, walker or other assistive device in order to leave your 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.
What Does Medicare Cover For Home Health Care In The Us
If youre looking for an answer to the question, what does Medicare cover for home health care in America?, youve probably typed it into google and immediately closed the tab. The volume of information and the level of detail can quickly become confusing and overwhelming .
Weve broken this important query down into a series of frequently asked questions, looking at what home health services can be offered by a home health agency, what services arent covered, and who is eligible.
If youre a health professional exploring the idea of establishing a home health agency or are trying to determine which services you can and cant offer, this article will help.
What Does Medicare Cover
The official Medicare website operated by the federal government provides lists and a searchable database of services and items covered by Medicare. Mobile apps for Apple and Android devices are available in the respective app stores.
Members can also discuss the required services and items with their doctor or health care provider. This is generally the most convenient way to find out whether Medicare will cover something, although doctors and other providers may not be aware of uncommon requirements.
Below, you can see an overview of what health and medical services are and are not covered by Medicare.
Covered By Medicare
Durable medical equipment and some other medical supplies
A few of the items and services mentioned above may be covered by Medicare health plans offered by private companies, such as Medicare Advantage plans, but in general, these will be out-of-pocket expenses. Additionally, coverage provided by these private insurance companies varies based on location and provider, so its important to check with your primary care physician and/or use the search function on the official Medicare website.
Medicare Supplement Plans Or Medigap
If you have original Medicare , you may be able to purchase a Medicare supplement plan, also called Medigap.
Some Medigap plans pay for the coinsurance costs for Part B, which may help you pay for home health services. However, these plans dont offer expanded home health service coverage.
Some people choose to purchase separate long-term care insurance, which isnt a part of Medicare. These policies may help to cover more home health care services and for longer time periods than Medicare. However, the policies vary and do represent an extra cost to seniors.
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Does Medicare Cover Home Health Care
Medicare covers limited home health services, including home health aides.
Home health aides are trained specially to assist with your care needs in the safety and comfort of your home. Medicare will pay for limited home health aide services if you meet eligibility requirements for home health care and receive your care from a Medicare-certified home health care agency.
Learn about Medicares stipulations and benefits for home health care coverage, including home health aide services.
How Long Does Medicare Pay For Home Health Care
Youve just found out that Medicare will pay for many of the home health care services your senior needs. Thats great news! The question now becomes, how long will that care last?If youre looking for care for your senior that is provided 24/7 around the clock, youll have to consider a nursing home or another option. Medicare doesnt provide coverage for such care.Instead, they emphasize that the care that is required must be intermittent. In other words, the senior either needs Fewer than 7 days of care each week or need daily care for less than 8 hours each day for up to 21 days.Additionally, Medicare also notes that it may extend the three week limit in exceptional circumstances if your doctor can predict when your need for daily skilled nursing care will end.
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Costs For Home Health Care Under Medicare
Original Medicare covers eligible home health care services at no cost to you if you meet certain requirements. For eligible durable medical equipment , youll pay 20% of the costs after meeting your Part B deductible.
Some or all of that coinsurance may be covered if you have a Medigap policy, which provides supplemental coverage to Original Medicare. With a Medicare Advantage plan, additional restrictions and costs may apply.
The costs for home health services can vary dramatically depending on where you live. The national average cost of hiring a health aide was $27 per hour in 2021, according to the most recent Cost of Care Survey from Genworth, an insurance company
Who Can Get Home Health Care With Medicare
Home health care provides a range of services in your home to help you recover from an illness or injury. Its an important part of medical care for people with disabilities or older adults who have difficulty getting out. Since you dont have to travel to a clinic or hospital for treatment, this type of care is very convenient.
If you need home health care, youll want to understand your insurance coverage so that youre not left with any unexpected bills. With Medicare Parts A and B, some home health care services are covered. Heres more information on those services, who qualifies for them, and which parts of home health care may be ineligible for Medicare coverage.
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Does Medicare Pay For Rehab After Hip Surgery
Many hip surgery patients are discharged from the hospital before theyre ready to live independently at home. Skilled nursing facilities like Bella Vista Health Center in San Diego provide a safe and comfortable place for patients to transition back to independent living. With access to a range of healthcare providers and rehabilitative services, residents are empowered to participate in their recovery while receiving the care they need to restore strength and functioning and get back to their personal best.
At Bella Vista Health Center, we often field calls from patients who have recently undergone or are preparing to undergo hip surgery, and who want to know if Medicare pays for rehab after hip surgery. The short answer is yes. But that wasnt the case just two years ago. Prior to 2020, total hip surgery was on a list of procedures that only qualify for inpatient medicare coverage, not rehabilitation coverage. In 2020, however, total hip surgery was removed from that list, making it available now for rehabilitation coverage through Medicare. There are, however, some stipulations, which well cover in the longer answer below. Read on for more information about Medicare and hip surgery rehab.
Medicare and inpatient rehabilitation
If youre enrolled in Medicare Part A, youll be happy to know that it covers medically necessary inpatient rehab care as long as your condition and the facility meet the qualifying requirements.
Medicare Covers Home Health Care In Limited Circumstances
Medicare will cover home health care for homebound seniors if they have been prescribed that care by a medical professional. Care services can include general personal care, however, home health aides may only be used on a part-time basis for no more than eight hours a day and a total of 28 hours per week.
Medicare Advantage may offer more support through its supplemental program, although individual insurers set their own policies to decide what additional coverage to provide.
Who Is Eligible For Medicare Home Health Care
Generally, anyone enrolled in Medicare Part A and/or Part B who meets the following conditions can have their home health care covered by Medicare:
- A doctor certifies that you are homebound
- You are under the care of a doctor
- A doctor certifies that you require one or more of the following:
- Part-time skilled nursing care
- Physical therapy, speech-language pathology, or occupational therapy services
Home health services are only covered by Medicare when they are specific, safe and an effective treatment for your health condition.
What Are The Benefits Of Home Health Care
The primary benefit of home health care for the elderly is that it can be delivered directly to the patients residence, whether it be a private home, adult foster home, assisted living or residential care facility, memory care facility, or long-term nursing home. By delivering care directly to the patient, expensive hospital bills can be avoided.
Family members are encouraged to be active participants in the planning process to help set and meet goals, working with home health care professionals for the benefit of the patient.
Additional benefits of home health care for seniors include:
- Faster recuperation and recovery from illness or injury
- Improved independence
Pros of Home Health Care
- Care is delivered directly to the patients residence
- Medical services are provided by skilled professionals
- Home health care staff follow the physician-prescribed plan
- Patients regain independence and self-sufficiency at home
- Care is typically less expensive than hospitalization or a long-term nursing home
Cons of Home Health Care
- Home care services like cooking and cleaning may not be included
- Patients must meet the homebound requirements to qualify for Medicare
- May not be adequate for patients who require 24-hour monitoring
- Can be expensive if not covered by insurance or Medicare
- Number of home health care providers may be limited depending on location
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Range Of Home Health Benefits
Medicare does not cover:
- 24-hour care at home
- Custodial or personal care when this is the only home care you need.
- Household services such as shopping, cleaning and laundry when they are not related to your care plan.
- Meal delivery to your home
Medicares website has a search and comparison tool to help you find certified home health agencies in your area. If you have original Medicare, Parts A and B, you can choose any approved agency.
If you have a Medicare Advantage plan from a private insurance company, you may have to use an agency that the plan works with. Before you start receiving care, the agency should let you know, verbally and in writing, whether some of the services they provide are not covered by Medicare and what you would pay for them.
Editor’s note: This article was originally published on Jan. 1, 2014. It has been updated with the latest information regarding Medicare coverage in 2020.
Medicare Coverage Of Senior Care
Enrollees in Medicare Part A and/or Part B may be covered for various in-home care services if a doctor has certified that theyre homebound. They may also be covered for nursing home care, but assisted living communities are generally not covered. Below, we explain the extent to which Medicare does or does not offer coverage for the main types of senior care.
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What Home Health Aide Services Are Covered By Medicare
Original Medicare generally only covers home health aide services such as skilled nursing care, occupational or physical therapy, or speech-language pathology services. If you only need home health aide services for help with bathing, dressing, and other activities of daily living , Original Medicare typically doesnât cover those services.
For example, letâs say your doctor arranges for home nursing and physical therapy visits to help you recover from a stroke. Medicare may cover part-time, intermittent home health aide services if your doctor believes they are medically necessary for your treatment plan.
Does Unitedhealthcare Cover Home Health Care
- Many UnitedHealthcare Medicare plans cover more home health care services than Original Medicare . Learn more and find UnitedHealthcare/AARP Medicare Advantage plans that pay for home health care.
Older adults often depend on home health care when recovering from surgery or injury or simply for help with daily activities that get more difficult with age. Without adequate health insurance, the cost of this type of care can weigh heavily on the finances of a retired person.
Some UnitedHealthcare Medicare plans can help cover home health care services and products. Learn more about the types of UHC Medicare plans that can help pay for home health care, what they cost and how you may be able to find a plan where you live that covers home health care and more.
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Does Medicare Cover Occupational Therapy At Home
Occupational therapy in a patients own home or residence is generally covered by original Medicare, Parts A, and B.
Occupational therapy helps patients navigate through sensory, cognitive, and physical problems. An occupational therapist may help patients refine their motor skills by working on keenness and concentration through picking items with tweezers. They also guide their patients through normal daily activities like dressing up or cooking.
The Difference Between Original Medicare And Medicare Advantage When It Comes To Home Care
The first important difference to note is that people with Original Medicare will usually be able to access care from almost any home health care provider . Conversely, people enrolled in Medicare Advantage plans may find that some providers do not accept their coverage. Additionally, we generally find that people with Original Medicare will receive more care services than those enrolled in Medicare Advantage plans. Disclaimer: This is a practical observation and each persons situation may vary.
As of 2019, Medicare Advantage plans are allowed to offer non-skilled home care among their supplemental services making assistance for just ADLs available to some consumers. While we feel this is a step in the right direction, we are not very optimistic about the amount of help that will be available through the plans that opt-in to providing this benefit. The reason for this boils down to money. The average Medicare Advantage plan receives roughly $800-$1,200/month per member. This is far from enough money to provide significant, non-medical home care services at scale. Here is a candid interview with a home care executive regarding this relatively new available benefit.
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How Long You Can Receive Home Health Services
For general home health services, youre covered for as long as youre eligible and your doctor recommends receiving those services. But skilled nursing care and home health aide services are covered only on an intermittent basis, which is defined as less than eight hours per day and 28 or fewer hours each week, once youre receiving care. If you need services beyond intermittent skilled nursing care or home health aide services, they will not be covered by Medicare.
The Medicare Home Health Benefit: An Unkept Promise
Associate Director, Center for Medicare Advocacy
Associate Director, Center for Medicare Advocacy
Misunderstandings about Medicare-covered home health care, along with changes in Medicare payment and regulations, have greatly restricted access to these important services
Home health benefits could help many beneficiaries with long-term or debilitating conditions, but a lack of information and misaligned incentives prevents them from receiving this care
Policymakers are grappling with how to increase access to home and community-based care and keep people out of skilled nursing facilities or hospitals, but they often overlook Medicare as a source of funding.
The Medicare home health benefit provides coverage for services that contribute to health, safety, and quality of life for beneficiaries and their families. In theory, coverage is available for people with both acute and chronic conditions and includes services to improve, maintain, or slow health declines. Such coverage is available even if services are expected to continue over a long period. However, changes in Medicares payment systems, quality measures, and audits designed to limit fraud have led to misunderstandings about whats actually covered by law. This has caused some home health agencies and other providers to curtail their services out of fear they will be audited or wont be properly reimbursed limiting beneficiaries access to care.
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