Medicare does cover home care in certain circumstances, but it’s critical to understand the specifics. For example, Medicare does not cover the cost of around-the-clock or custodial care, such as the type typically provided in nursing homes.
Medicare will cover home health care if the individual is homebound and requires skilled nursing care or therapy services. It also covers home health aide services if prescribed as part of the individual’s care plan. Additionally, Medicare can provide coverage for medical supplies, equipment, and certain medical social services related to home healthcare. However, it’s important to note that Medicare typically does not cover 24-hour-a-day care or homemaker services.
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The Increasing Need for Home Healthcare for Older Adults
As the U.S. population ages, a larger portion of older adults have found themselves homebound due to chronic illnesses, functional impairment, or cognitive issues. The term “homebound” may be used to describe individuals who leave their homes once a week or less, excluding visits to a religious institution or adult day care. These individuals are typically socially isolated and likely have unmet healthcare needs.
A survey conducted in 2020 found that the number of homebound adults aged 70 or older more than doubled in a single year, increasing from an estimated 1.6 million in 2019 to approximately 4.2 million in 2020.
Homebound individuals generally cannot leave their homes without considerable effort and assistance. Regular tasks such as grocery shopping, visiting a doctor, or attending social functions may be challenging for these people.
Therefore, medical home health care can become indispensable for this population. For example, those with difficulty leaving the house may need professional caregivers for wound care, physical therapy, or medical supply management services. Further, sufficient home care can reduce hospital readmissions and improve overall health outcomes for homebound individuals.
It’s important to note that while Medicare covers home health care, it does not cover custodial or non-medical care services, which can be a common need. Understanding Medicare’s eligibility requirements and coverage rules can help homebound individuals and their caregivers make informed decisions about their healthcare needs.
Understanding Medicare Coverage for Home Health Care and Home Caregivers
When discussing Medicare coverage, it’s important to understand the distinction between home medical care and home custodial care. Home medical care refers to professional medical services provided in the home, such as wound treatment, medication management, and health monitoring. Medicare typically covers these services as long as the eligibility requirements are met.
Home custodial care includes help with activities of daily living like bathing, dressing, meal preparation, and housekeeping. Medicare typically does not cover custodial care.
Eligibility Criteria
Medicare has specific eligibility criteria for home care coverage. First, your doctor must certify that you are homebound and create a care plan that involves skilled care provided by a caregiver from a Medicare-certified home health agency. You must also be actively recovering. If your condition is stable, Medicare does not cover caregiver costs, even if some home assistance is still needed.
Specific Home Health Services Medicare Covers
- Part-time or intermittent skilled nursing care – Care that can only be administered by a licensed nurse.
- Physical therapy – Exercise that helps you regain strength and movement in a specific area of the body.
- Occupational therapy – Education regarding how to perform daily activities.
- Speech-language therapy – Exercises to help regain and strengthen speech skills.
- Home health aid – Help with activities like bathing and dressing (must be part-time or intermittent and paired with skilled nursing care).
- Medical social services – Counseling for emotional and social concerns related to the illness (covered when paired with skilled nursing care).
- Medical supplies for use at home – Excludes biologicals (e.g., vaccines) and prescription drugs.
- Durable medical equipment – Items such as wheelchairs, walkers, and oxygen equipment.
Excluded Home Health Services
Medicare maintains a list of home health services that are not covered. However, some types of Medicare Advantage plans may offer extended benefits that provide additional coverage. Under Original Medicare, the following services are excluded from coverage:
- 24-hour home care
- Prescription drugs (excluding injectable medications for osteoporosis)
- Meals delivered to your home
- Homemaker services like shopping, cleaning, and laundry
- Custodial care (e.g., help with dressing or bathing) when it is the only form of care needed
Hospice Care with Medicare
Hospice care differs from regular home health care as it’s specifically designed for individuals with a terminal illness with a life expectancy of six months or less.
To be eligible for Medicare-covered hospice care, you typically must receive certification from both your regular doctor and your hospice doctor stating that you are terminally ill and are expected to live for six months or less. In addition, you must accept palliative care, also known as comfort care, rather than care designed to cure your illness. Finally, you must sign a statement indicating that you’ve elected hospice care instead of other Medicare-covered treatments for your terminal illness and other related conditions.
How Does Medicare Advantage Cover Home Health Care?
Medicare Advantage, or Medicare Part C, is an alternative to Original Medicare (Parts A and B). Part C plans are provided by private insurance companies but are required to offer, at a minimum, the same benefits as Original Medicare. Many Medicare Advantage plans also offer additional benefits, which may include home healthcare services that Original Medicare excludes.
Medicare Advantage plans may also have more flexibility regarding eligibility requirements for home health care. However, benefits, costs, and eligibility can vary significantly between different Medicare Advantage plans, so it’s important to carefully review the specifics before choosing a plan.
How Much Does Home Health Care Cost with Medicare?
Depending on the type of home health care needed, Medicare-covered individuals may have out-of-pocket expenses, including deductibles, copayments, and coinsurance. The total cost depends, in part, on whether the service is covered by Medicare Part A or Part B. Let’s take a closer look at the specifics.
Part A Costs
Many Medicare-covered individuals are eligible for premium-free Medicare Part A coverage, meaning no monthly premium is due. Medicare Part A covers eligible home health services at a $0 out-of-pocket cost.
If you need durable medical equipment, such as a hospital bed, wheelchair, or walker, there is a required coinsurance of 20% of the Medicare-approved amount.
Part B Costs
Medicare Part B has a base monthly premium of $164.90 in 2023. When receiving covered home health services under Medicare Part B, recipients have a $0 out-of-pocket cost. For durable medical equipment, there is a 20% coinsurance on the covered amount after the annual Part B deductible ($226 in 2023) has been met.
How Medigap Can Help with Costs
Medigap is a supplemental insurance policy sold by private companies to help pay some of the healthcare costs that Original Medicare does not cover, such as coinsurance, copayments, and deductibles. Since both Medicare Part A and Part B provide covered home health services with no out-of-pocket cost, there is no need for a Medigap policy to offset expenses.
However, when approved durable medical equipment is needed while receiving home health care, a Medigap plan can help cover the 20% coinsurance cost.
Medicare Advantage Costs
Medicare Advantage plans are required to provide, at a minimum, the same level of home health care coverage as Original Medicare. However, Part C plans may have different rules, restrictions, and home health care coverage expenses. Some of the factors that may contribute to your out-of-pocket costs under a Part C plan include:
- Premiums – A monthly cost paid whether you use your plan or not. Part C premiums are in addition to the Part B premium, but some Part C plans are premium-free.
- Deductible – The amount you must pay out-of-pocket before your plan begins to pay.
- Copays – A fixed amount paid for each healthcare service or supply.
- Coinsurance: A specific percentage of the costs of a covered health care service, paid after you’ve paid your annual deductible.
- Healthcare networks – Some plans have a network of pre-approved doctors and healthcare providers. Seeking care outside the network may result in higher costs.
- Out-of-pocket maximums – The maximum amount you have to pay for covered services in a plan year. Once the limit is reached, you pay nothing for covered services for the remainder of the year. The 2023 maximum is $8,300.
How to Find a Medicare Caregiver
Other Options for Home Health Care
While Medicare can provide essential coverage for home health care, there may be situations when supplemental or alternative coverage is needed. If a situation requiring alternative care arises, the following resources may be helpful.
Skilled Nursing Facility Stays
Medicare Part A covers inpatient care in a skilled nursing facility (SNF) following a qualifying hospital stay. To receive SNF coverage, you typically must be in the hospital as an inpatient for a minimum of three days and must enter the facility within a short time (generally 30 days) after your hospital stay.
Medicare-covered services in a skilled nursing facility may include semi-private rooms, meals, skilled nursing care, physical and occupational therapy, certain home health services, and dietary counseling.
Medicare Special Needs Plans (SNPs)
SNPs are a type of Medicare Advantage Plan designed for people with specific diseases or characteristics. For example, there are SNPs for those with chronic conditions like diabetes or heart failure and those eligible for Medicare and Medicaid.
SNPs may include broader home health care coverage, particularly if the covered illness is likely to require it. SNPs may also have additional benefits, such as care coordination and wellness programs.
Medicaid
Medicaid is a joint federal and state program that provides health coverage for some low-income adults and certain older adults, pregnant women, children, and people with disabilities.
In some cases, Medicaid may cover additional home healthcare services not covered by Medicare. Each state operates its own Medicaid program within federal guidelines, so coverage can vary significantly.
Private Caregiving Insurance and Programs
Some individuals may have access to private insurance options that can provide additional support for home health care. For instance, long-term care insurance policies may cover the cost of home health care that Medicare does not cover.
Some employers might offer caregiving support programs, which provide resources, referrals, and financial assistance for employees caring for a loved one.
Community and Charitable Organizations
Community and charitable organizations can be a lifeline for homebound individuals, providing services that enhance the quality of life and safety. Programs may include delivered meals, transportation assistance for medical appointments, and adult day centers that offer respite for caregivers.
Some organizations offer home modification programs, making homes safer for older adults or those with disabilities. Local Area Agencies on Aging can typically provide information regarding available resources.
Support For Caregiving Providers
Caring for a loved one at home may involve more than providing medical attention. Home health care typically also includes assistance with daily living, emotional support, and companionship.
Caregivers can come in different forms, from family members stepping up to provide care to professional caregivers and home health aides employed for their specialized skills. Each caregiver type is critical, with family members sometimes stepping out of their comfort zone to fulfill multiple roles and professionals delivering expert care that is outside the expertise of family members.
Regardless of their role, caregivers face unique challenges. Balancing caregiving with other responsibilities like work and family can lead to physical and emotional stress. Caregivers must have access to support and resources to avoid burnout to provide ongoing care.
There are several programs and resources available to aid caregivers, including:
- The Program of All-Inclusive Care for the Elderly (PACE) – Offers a comprehensive array of health services for eligible individuals over a certain age. Services may include in-home care, daytime care in health centers, and support for family caregivers.
- The National Family Caregiver Support Program (NFCSP) – Provides grants to states to fund a range of support for caregivers, including counseling, respite care, and training.
- Local community programs – Offer resources such as caregiver support groups, educational programs, and respite care.
Putting It All Together
Medicare’s coverage for home health care may seem complex. However, the essential takeaway is that Medicare does provide coverage for certain home health services, as long as the person is homebound and the care is medically necessary and on an intermittent basis.
Beyond Original Medicare, options like Medicare Advantage, Medigap, and Medicaid can offer expanded coverage. Resources are also available to support the caregivers who provide home health care. Understanding these three key points can help you navigate the home healthcare landscape and make informed decisions that suit your unique circumstances.