Home health services allow a person to remain in their home while they receive needed therapies or skilled nursing care. Medicare covers some aspects of these home health services, including physical and occupational therapy as well as skilled nursing care.
However, Medicare doesn’t cover all home health services, such as around-the-clock care, meal delivery, or custodial care — many of these services fall under those of a home health aide.
Keep reading to find out about covered services under Medicare, and how home health aides may or may not fall under this category.
Home health aides are health professionals who help people in their home when they have disabilities, chronic illnesses, or need extra help.
Aides may help with activities of daily living, such as bathing, dressing, going to the bathroom, or other around-the-home activities. For those who need assistance at home, home health aides can be invaluable.
However, they’re different from other home health occupations, which can include home health nurses, physical therapists, and occupational therapists who provide medical and skilled care that requires extensive special training and certifications.
According to the U.S. Bureau of Labor Statistics, the typical educational level for a home health aide is a high school diploma or equivalent.
Some people may use the term “home health aide” to describe all occupations that provide care at home, but a home health aide is technically different from a home health nurse or therapist.
These differences are key when it comes to understanding what Medicare will and won’t cover when it comes to home care. Medicare doesn’t pay for most services that fall under health aide services. These include:
- around-the-clock care
- home meal delivery or help with eating
- homemaker services, such as doing laundry, cleaning, or shopping
- personal care, such as help with bathing, getting dressed, or using the bathroom
If personal care services from a home health aide are the only care you need, Medicare doesn’t usually cover these. They do cover home medical care services.
Ideally, home health can enhance your care and prevent re-admission to a hospital. There are several steps and conditions to qualify for home health care:
- You must be under the care of a doctor who has created a plan for you that involves home health care. Your doctor must review the plan at regular intervals to make sure it is still helping you.
- Your doctor must certify that you need skilled nursing care and therapy services. To need this care, your doctor must decide that your condition will improve or maintain through home health services.
- Your doctor must certify that you are homebound. This means it is very difficult or medically challenging for you to leave your home.
If you meet these requirements, Medicare parts A and B may pay for some home health services, including:
- part-time skilled nursing care, which could include wound care, catheter care, vital signs monitoring, or intravenous therapy (such as antibiotics)
- occupational therapy
- physical therapy
- medical social services
- speech-language pathology
According to Medicare.gov, Medicare does pay for “part-time or intermittent home health aide services.” This is understandably confusing.
It means that a home health worker may provide personal care services that a home health aide provides. The difference is that, for reimbursement, you must be getting skilled nursing services as well.
If your doctor has taken the steps to help you qualify for home health services, they’ll likely help you contact a home health agency.
These organizations should provide you with an explanation of what Medicare does and doesn’t cover through an Advance Beneficiary Notice. Ideally, this helps to cut down on surprise costs to you.
When Medicare approves your home health services, you may pay nothing for home health care services, though you may be responsible for 20 percent of the Medicare-approved amount for durable medical equipment (DME), which may include physical therapy supplies, wound care supplies, and assistive devices.
There is usually a 21-day time limit for how long you can receive cost-free services. However, your doctor can extend this limit if they can estimate when your need for home health services may end.
Medicare divides its services into different letter groupings, including Medicare parts A, B, C (Medicare Advantage), and D (prescription drug coverage).
Medicare Part A is the portion that provides hospital coverage. Medicare Part A is free to most individuals when they or their spouse worked for at least 40 quarters paying Medicare taxes.
Although Part A is “hospital coverage,” it still covers skilled home health services because they can be a continuation of the care you were getting at the hospital and vital to your overall recovery.
Medicare Part B is the portion that covers medical services. Everyone in Part B pays an insurance premium, and some people may pay more based on their income. Part B pays for some aspects of home health services, including medical equipment.
Medicare Part C is also known as Medicare Advantage. It’s different from traditional Medicare in that it combines parts A, B, sometimes D (prescription drug coverage), and sometimes additional services, depending upon your plan.
Examples of Medicare Advantage Plans include health maintenance organization (HMO) or a preferred provider organization (PPO). If you have these plan types, you’ll likely need to get your home health services from an agency your plan specifically contracts with.
Some Medicare Advantage plans provide further coverage for home health services, and this information should be included in your explanation of benefits.
Medicare supplement plans or Medigap
If you have original Medicare (parts A and B, not Medicare Advantage), 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 don’t offer expanded home health service coverage.
Some people choose to purchase separate long-term care insurance, which isn’t 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.
Medicare doesn’t pay for home health aide services in the absence of the skilled care designation. If your doctor says you need skilled care, you may be able to receive personal care services while getting skilled care.
The best approach is to communicate with your doctor and the prospective home health agency to understand what costs are and aren’t covered and for how long.
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