Families Are Quite Distressed When They Discover That Medicare Will Not Pay For A Home Caregiver
Families are often surprised if not dumbfounded to learn that Medicare does not pay for most in-home care for their elderly parents. Medicare will not reimburse in-home caregivers to assist aging loved ones with basic activities of daily living such as personal care, meal preparation, transportation, medication reminders and housekeeping. In-homecare often referred to as custodial care is not covered by Medicare in spite of the dire need of these services by countless seniors. Furthermore it is exactly these non-medical homecare services that enable seniors to remain safely in their homes and age with dignity. Home care that is considered non-medical in nature is sadly not an allowable expense covered by our national Medicare program. Whether it is part-time, fulltime, or even live-in homecare the answer is still a resounding NO when it comes to Medicare reimbursement. Numerous families understandably are quite distressed when they unexpectedly discover that Medicare will not pay for in-home care to support their aging parents.
About the Author
Clare Absher is a Registered Nurse with 43 years of experience. Most of her experience is in home health serving as a caregiver, educator, patient advocate, and liaison between families and community resources. She has also worked in acute care, assisted living, and retirement settings. She is passionate about helping families care for their elderly loved ones at home.
What Is The Medicare Pace Program
PACE stands for Program of All-inclusive Care for the Elderly.
In some states, this program is called LIFE, which stands for Living Independence for the Elderly.
PACE / LIFE is a Medicare and Medicaid program that provides home-based care and services to people aged 55+ who qualify for a nursing home level of care.
The programs goal is to help older adults stay in their homes as they age instead of having no choice but to move to skilled nursing facilities.
When Might Medicare Cover In
In general, Medicare doesnt cover long-term home health care. Heres how Medicare coverage of in-home health care typically works.
In most cases, even when Medicare covers in-home health care, its for part-time care, and for a limited time. Some of the requirements may include:
- You must be under the care of a doctor, who must have a plan of care for you that she or he regularly reviews.
- The in-home health agency must be Medicare-approved.
- Your doctor must certify that youre unable to leave your home without some difficulty for example, you might need transportation and/or help from a cane, a walker, a wheelchair, and/or someone to help you. In other words, youre homebound.
- Your doctor has to certify that you need certain kinds of in-home care, such as:
- Skilled nursing services when you dont need constant care. That is, you need these services intermittently.
- Continued occupational therapy*
- Speech language pathology*
This may not be a complete list.
*Medicare has certain rules about covering this type of service. If your doctor orders it for you, you may want to contact your Medicare Advantage plan, or Medicare, to see if itll be covered. Contact information for Medicare is at the bottom of this page.
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Does Medicare Cover Unskilled Home Care Services
Medicare will not pay for unskilled home care if those are the only services needed. Personal home care services or homemaker services will only be covered if they are part of the skilled services detailed in the care plan. Medicare does not cover around-the-clock home care of any kind or meals delivered to the home.
Medicare Coverage Of In
In-home health care may be covered if its medically necessary. It must also be part-time or intermittent, which rules out full-time and long-term care in the home. Home health services such as skilled nursing care, home health aide services, physical and occupational therapies and medical social services are covered by Part A and/or Part B.
Medicare doesnt cover non-medical care and services provided in the home, including meal deliveries. Homemaker services and personal care, such as help with chores and assistance with the activities of daily living, may be covered only when provided alongside other medically necessary care.
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Learn How To Schedule In
Everyone needs a little extra help sometimes. Thats especially true if youre dealing with a serious medical condition or recovering from a procedure. For example, maybe youre finding it hard to manage your medications or personal care. Or perhaps standing for long periods of time to cook a healthy meal or take care of necessities around the house is simply too much right now.
If that sounds familiar, an extra set of hands might be just what the doctor ordered and thats where a home health aide can help. A home health aide is someone who can help you with non-skilled care in the comfort of your own home. In other words, they can help you with day-to-day living activities. But not with services a health care worker like a nurse or physical therapist offers.
Best of all, a home health aide may be covered by your plan, provided you have a doctor or hospital order and plan of care. Heres what you need to know.
Whos eligible for a home health aide
You may be able to get a temporary home health aide if you meet all the following qualifications:1
Home health aides through Medicare are approved for only up to 21 days. If you need longer-term care, then you may be eligible for a home health aide through your state via a Medicaid waiver, says Nicole Wolf, RN, manager of Clinical Health Services at Aetna®. Your hospital, doctor or insurance case manager can help you find out if you qualify.
What to expect during your in-home visits
- Give you medications.
How To Get Home Health Care
To start home health care, your doctor will have to prove to Medicare that one or more of the following apply to you:
- You need skilled nursing care
- You need physical therapy, speech therapy, or occupational therapy
- Youâre homebound
âSome rules are slightly changed as a result of the pandemic,â Schwarz says. âFor instance, the definition of âhomeboundâ is broadened. Your health care team could state that itâs not advisable that you leave home right now.â
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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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How Can I Get Free At
All Americans regardless of their insurance coverage were eligible for free at-home COVID-19 screening tests from the federal government. Each household qualified for two free shipments of four tests each. The quantity limit may not have been adequate for larger families, but some free testing is better than none.
The tests were shipped through the U.S. Postal Service. The free at-home COVID-19 test program ran from January 19, 2022 to September 2, 2022. Although the federal government is not providing free tests at this time, it has taken steps to ensure that people are able to get free tests through their health insurance Medicare included.
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Do Medicare Advantage Plans Cover In
Medicare Advantage plans provide your Medicare Part A and Part B coverage. Instead of getting Part A and Part B through the federal government directly, you get them through a private insurance company that contracts with Medicare.
So, your in-home health care benefits will be at least the same as what Medicare Part A and Part B offer . Medicare Advantage plans may have annual deductibles, and may charge coinsurance or copayments for these services. Medicare Advantage plans have out-of-pocket maximum amounts, which protect you from unlimited health-care spending.
Youll need to keep paying your Medicare Part B premium when you have a Medicare Advantage plan.
Want to learn more about Medicare Advantage plans? Its easy to take a look at the plans in your area and see what benefits they offer besides Medicare Part A and Part B coverage. Just type your zip code in the box on this page, and you can compare Medicare Advantage plans at your convenience.
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.
Original Medicare Vs Medicare Advantage When It Comes To Home Care
To properly understand the differences between Original Medicare and Medicare Advantage plans when it comes to home care, it is important to first understand the difference between the two coverage options themselves:
People may receive their Medicare in two different forms, Original Medicare or via a Medicare Advantage plan.
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Reverse Mortgages & Helocs
Families can self-pay for care by using their home as a financial resource. Two options include reverse mortgages and home equity lines of credit. However, depending on ones marital status, their severity of need and the projected length of need, these options might not make economic sense. For example, if the person in need of care is single and may need to move into residential care within a two-year period, then a reverse mortgage is probably not the best option. Read more about when it is best to use each of these options and their pros & cons at the following links: Reverse Mortgages& Home Equity Lines of Credit
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Who Is Eligible For In
In order to access the available home health care services, your client will need to have Medicare Part A and/or Part B. In addition, they need to meet the following conditions:
- They must be under the care of a registered doctor, and their case must be reviewed regularly by their doctor.
- Their doctor must certify that they need skilled nursing care or therapy.
- They must require physical, occupational, or speech therapy for a limited period of time.
- They must be housebound, meaning that they are unable to leave home without considerable effort or support.
- They must have certification from a doctor that theyre housebound following a documented encounter with their doctor no more than 90 days before or 30 days after their home health care starts.
- They are under an established plan of care from their doctor that is reviewed regularly and includes what services are needed, how often they are needed, who will provide them, what supplies are required, and what results are expected.
- They must only require part-time skilled nursing .
- You, as the home health agency providing care, must be Medicare certified.
A client will not be eligible for home health benefits if they require more than intermittent skilled nursing care. However, they may leave their home for medical treatment for short outings such as religious services. Your client will still be eligible if they attend adult daycare.
For more on who qualifies for services, have a look at Medicares website.
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Does Medicare Cover In Home Care
The short answer to this yes, but there are some exceptions. In order to get the in-home care, each person will have to meet certain eligibility requirements, and the services needed must be determined to be reasonable and necessary for the treatment of your illness or injury.
Who is eligible for in-home care paid for by Medicare?
As mentioned, there are certain requirements for people to qualify for in-home care to be paid for by Medicare.
To qualify, here is what youll need to qualify
- Being under the care of a doctor, and the services are being provided under a care plan that is established and reviewed regularly
- A doctor has certified that you need one of the following
- Intermittent skilled nursing which means less than 7 days a week and for less than 8 hours each day
- Speech and language services
- Occupational therapy on an on-going basis
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 this type of 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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What Types Of In
If your situation meets Medicare criteria, Medicare may cover in-home health care such as:
- Skilled nursing care
- Part-time home health aides
- Medical social services
Medicare benefits might also cover:
- Durable medical equipment
- Medical supplies
- Injectable osteoporosis drugs
If you qualify for home health care under Medicare, you generally dont have to pay any coinsurance or copayment. If you need durable medical equipment, youll typically pay 20% of the Medicare-approved amount as coinsurance. Read more about Medicare and durable medical equipment.
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.
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Does Medicare Pay For Caregivers
A person must meet specific eligibility rules to get home care services, and sometimes, extra costs may apply that Medicare does not cover.
This article discusses the different types of caregivers, what Medicare pays for, and help with out-of-pocket costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
There are different types of in-home caregivers. Some help with nonmedical personal care, while others offer medical services.
Common types of caregivers include:
Medicare pays for caregivers when:
- a person is under the care of a doctor
- a doctor has certified a person as homebound
- the care delivered is through a written plan that the doctor regularly reviews
- part-time skilled nursing care
Medicare Advantage May Offer More Comprehensive Coverage
Private insurance companies run Medicare Advantage. Those companies are regulated by Medicare and must provide the same basic level of coverage as Original Medicare. However, they also offer additional coverage known as supplemental health care benefits.
These benefits can be used to cover the cost of health care or medical equipment that could reduce the risk of injury, reduce the impact of lost mobility or injury or help a person maintain their health and independence.
Medicare Advantage covers many services that are excluded from original Medicare. Individual insurers are permitted to exercise discretion when deciding what services to offer under supplemental benefits, so Medicare Advantage customers should contact their insurers to discuss their options before deciding on a care plan.
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What Are Medical Social Services
These are medically prescribed services to help the patient cope emotionally in the aftermath of an illness or disease. Examples of medical social services that Medicare covers include in-home counseling by a licensed therapist or social worker. Keep in mind that these services are only covered by Medicare if the client is receiving skilled nursing care at home.