Medicare Your Coverage Options

Need home health care? Don’t count on Medicare

Written by Diane Archer
Of all the failings with the US health care system for older Americans and people with disabilities, one of the greatest is Medicare’s very limited home care coverage. Millions of Americans need home care as they age or when they have a disability. And, Medicare does not begin to meet their needs. It never covers custodial care or round the clock care. And, it generally pays for no more than 15 or 20 hours of care weekly.

When will Medicare cover your home care? For Medicare to cover your care at home, you must receive your home health care from a Medicare-certified home health agency and meet the following three additional conditions:

  1. You must need skilled nursing or therapy services on an intermittent basis, as little as once every 60 days or daily for a finite and predictable period, usually no more than a few weeks. Skilled nursing includes observation and assessment, catheter changes and wound care. Skilled therapy includes physical, speech and occupational therapy, both to improve your condition and to maintain your condition.
  2. You must be homebound, which means that leaving home requires a considerable and taxing effort.
  3. Your doctor must certify your need for home care and sign off on your plan of care.

What does Medicare cover? If you qualify for Medicare-covered home care, in addition to paying the full cost of skilled services, Medicare pays for a limited number of hours of home health aide services to help with bathing, dressing, feeding, toileting and transferring. Medicare covers the cost in full; patients have no deductibles or copays. Note: Medicare does not pay for home health aide services if you do not need skilled services. Medicare also sometimes pays for medical social services, if needed and ordered by your treating physician, and durable medical equipment.

How much care does Medicare cover? Medicare pays for skilled services and home health aide services. Home health agencies generally provide no more than eight hours a day of care, with a maximum of 35 hours a week but usually no more than 28 hours.

How long will Medicare cover your home care? Unlike with hospital and skilled nursing facility care, Medicare imposes no limit on the number of days of home care it will cover for people who meet the qualifying criteria. In a legal case settled in 2013,  Medicare agreed that patients can receive Medicare-covered care to maintain their condition or prevent decline; they do not need to be improving.

However, Susan Jaffe reports for Kaiser Health News that homebound patients with chronic conditions whose doctors certify that they need intermittent skilled services are hard-pressed to find a home health agency to provide them the Medicare-covered services to which they are entitled. Home health agencies fear that if they provide extended home care services, Medicare will deny them payment for that care. In fact, in fiscal year 2017, Medicare found that one out of three claims billed by these agencies should not have been paid.

If Medicare denies payment for a home health service, the home health agency is liable, not the patient. So, home health agencies want to reduce their risk of having Medicare deny services they provide.

What should you do if an agency refuses to provide home care and your doctor says that you meet the qualifying criteria? You should appeal. You will likely win. However, you will likely assume the responsibility of paying for the services you receive if Medicare denies your appeal.

How can you find a Medicare-certified home health agency? Call 1-800-Medicare (1-800-633-4227) or contact your local hospital for Medicare-certified home health agencies in your area.  If you’re in a Medicare Advantage plan, a commercial health plan offering Medicare benefits, call the plan directly to find out what agencies can provide your home care.

Keep in mind: Medicare will not cover home care for people who need round the clock or extensive home health services. You should call your state health insurance counseling program to learn about programs for older adults available in your community.

Medicaid sometimes provides home care and, if not, it covers nursing home care, including custodial care.  Long-term care insurance might also pay for home care, though many people are better off saving the money on those premiums and paying for home care directly.

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