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Does Medicare Cover Home Health Care?

Updated: Dec 1, 2023

In the world of health care and insurance, uncertainty often looms. One frequent question is: does Medicare provide coverage for home health care? If so, what makes you eligible, and what portion, if any, will you bear out-of-pocket? We need to break down Medicare and its connection to home health care to get clear answers.

Understanding Medicare

To understand Medicare and home health care, learn about Medicare's various aspects. Medicare, a health insurance program primarily for people aged 65 or older, comprises Parts A, B, C, and D. There are different parts of healthcare, like hospital insurance, medical insurance, Medicare Advantage plans, and prescription drug coverage.

How Original Medicare Covers Home Health Care

Original Medicare combines Part A and Part B. Original Medicare includes more than just hospital stays and doctor visits. It also covers necessary home health care services. If your doctor prescribes home health care, you need part-time skilled nursing care or therapy.

Under Original Medicare's scope, home healthcare services are quite comprehensive. Medicare Part A and Part B cover home health care, including nursing care, therapy, and occupational services. The keyword here is 'medically necessary'. A doctor prescribes these services and must be Medicare-approved as part of a care plan.

You won't have to pay for most services if you qualify for home health care under Original Medicare. This includes home health care services and durable medical equipment (like wheelchairs and walkers).

Medicare Advantage and Home Health Care

Medicare Part C or Medicare Advantage plans are offered by approved private insurance companies. They provide all benefits under Part A and Part B. Some also cover prescriptions and offer extra benefits not in Original Medicare.

How Medicare Advantage plans cover home health care can vary. Some may provide extra home health benefits like delivering meals or offering transportation to medical appointments. Others may even cover long-term care services not covered by Original Medicare. Home health care costs can vary significantly between Medicare Advantage and Original Medicare. The important thing to consider when choosing a plan is what kind of care you expect to need.

Medicare and Long-Term Home Health Care

A common question is whether Medicare covers long-term home health care. Original Medicare covers acute care, not long-term care. If you need 24/7 or primary personal care, Original Medicare won't usually pay for it.

Long-term care is different from home health care under Medicare. If you need long-term care at home, consider Medicaid, long-term care insurance, or personal savings to cover the costs.

Medicare Supplemental Coverage for Home Health Care

Original Medicare covers most of home health care costs, but not everything. Individuals can choose a Medigap plan to cover the gaps in Original Medicare. Medigap plans cover co-payment and deductible costs for approved home health care services.

Private insurance companies offer Medigap plans, but coverage and availability may vary. Research and compare plans thoroughly if you plan to use home health care services.

Medicare Home Health Care Eligibility Criteria

It's important to look at Medicare's criteria for home healthcare coverage. These rules ensure that only those needing home health care get coverage.

  • Doctor-prescribed care plan: A doctor should determine that you require home health care services. They must create a care plan, including home health care for your needs. This plan should cover skilled nursing care, physical therapy, speech-language pathology, or ongoing occupational services.

  • Homebound status: Medicare requires people to be medically homebound. This means they should avoid leaving home due to their condition or if it requires much effort. Accommodations may involve using a wheelchair or walker or needing help leaving.

  • Certification: Medicare requires doctors to reassess your homebound status and recertify the need for ongoing home health care every 60 days. This ensures your condition has stayed the same for coverage.

What Services are Not Covered by Medicare Home Health Care?

Knowing what Medicare doesn't cover for home health care is important, too. The following services are typically not covered:

  • 24-hour-a-day care at home: Medicare will not pay for around-the-clock home health care services.

  • Meal delivery: Generally, Original Medicare does not fund prepared meal deliveries to your home.

  • Personal care services: Medicare does not cover bathing, dressing, and grooming if not provided with skilled medical care.

  • Custodial care: Help with daily activities like cleaning, cooking, or shopping is not covered by Medicare unless provided by a trained healthcare professional.

  • Non-medical transportation: Original Medicare doesn't usually pay for transportation expenses like grocery shopping.

These instances emphasize the services that Medicare deems medically unnecessary. Some mentioned services may be included in certain Medicare Advantage plans based on the plan's offerings.

Preparing for Out-of-Pocket Costs

It's important to think about your finances when planning for home healthcare. Medicare covers a lot, but check your policy for additional costs like co-pays or deductibles.

To plan for home healthcare, consider setting aside funds for these expenses. You can consider a Medicare Supplement plan or a Medicare Advantage plan that suits your needs better.

Understanding Medicare means knowing your choices and anticipating your personal needs. Remember that Medicare's home health care covers medically necessary services on a part- or full-time basis, not long-term custodial care. Original Medicare covers these services at no cost, but Medicare Advantage plans may provide extra coverage with varying out-of-pocket expenses.

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