Each year, millions of people require home health care services. Most people who receive these services do so because they need a greater degree of care on a regular basis and are unable to receive this care outside of their home. Usually, you can work with a home health care company to help you organize your care, but this can add to the expenses.
Luckily, the Medicare program can offer some coverage for many home health services, though others fall under what’s called long-term care. What’s the difference between the two, and how do you qualify for Medicare insurance home health care coverage?
For full details on the Medicare program’s coverage of home health care services, check out the Centers for Medicare & Medicaid Service’s official booklet on the topic.
What is Home Health Care?
Home health care is a fairly wide category of services, which is why certain aspects of it aren’t always covered by Medicare insurance. Officially, home health care consists of various health care services that are provided in a beneficiary’s home under a plan from their doctor.
Home health care: health care services that are provided at your home under a plan from your doctor.
How is It Different Than Long-Term Care?
The main difference between home health care and long-term care involves the type of care provided. With long-term care, a home health aide often provides someone with “custodial care,” assistance with day-to-day needs like bathing, eating, or cleaning the home. These aides don’t need to be medically trained. Medicare insurance will not cover “custodial” long-term care because it is not seen as “medically necessary.” On the other hand, home health care services are health services given in the home by trained medical professionals (e.g., nurse, physical therapist, occupational therapist) and as part of an overall health plan created by your doctor. The goal of home health care is to treat an illness or injury, help you regain independence, or help you maintain your current quality of life despite a chronic illness (or at least slow the decline). The Medicare program will usually cover home health care services that are “medically necessary.”
Home health care services are health services given in the home by trained medical professionals and as part of an overall health plan created by your doctor.
Another difference between long-term care and home health care is how long the care is provided. Long-term care is usually provided for months or years; whereas home health care is often temporary and only for a few weeks.
Eligibility for Medicare Insurance Coverage of Home Health Care
It’s all well and good knowing exactly what home health care is, but the important question for many remains. How do you know if the services you’re receiving qualify for Medicare insurance coverage?
There are five key requirements that determine your eligibility.
- You must be receiving care as part of an overall plan by a doctor. This plan must be reviewed and managed regularly.
- As part of this plan, your doctor must certify that you need a number of services like intermittent skilled nursing care (for services other than drawing blood), physical therapy, continued occupational therapy, and medical social services, to name a few.
- The home health care company that you use must be Medicare-certified.
- Your doctor, or certain health care professionals, need to document a face-to-face meeting with you related to your care within specific time frames.
- The final requirement is that your doctor certifies that you’re homebound.
Homebound often, but not always, means you’re unable to leave the house. Truly, it means that you struggle leaving home without help (usually with the aid of a cane, other durable medical equipment (DME), or a caregiver). So, homebound doesn’t mean you can’t leave the home, just that leaving takes great effort or isn’t advisable due to an injury or illness. Even if you’re homebound, you may be able to leave your house for short, infrequent trips like a short walk, family events, religious services, or for some medical treatments.
What Do You Pay If You Get Medicare Insurance Coverage?
If you qualify for home health care coverage through Medicare, you won’t pay out of pocket for the services. If you require DME, you’ll only owe 20 percent of the Medicare-approved amount for it. Any other costs, like DME or services provided that aren’t covered by Medicare, should be outlined by the health care agency both verbally and in writing.
Any other costs, outside of 20 percent of the Medicare-approved amount, should be outlined by the health care agency both verbally and in writing.
The agency must also provide an Advance Beneficiary Notice of Noncoverage (ABN). An ABN outlines what services or equipment won’t be covered and why the Medicare program won’t be covering it. You can choose to appeal this decision to try and get coverage.
What Are My Other Options?
If you aren’t eligible for home health care coverage under Medicare, there are ways you may be able to receive similar services that should be covered by Medicare insurance. If you struggle to leave home, you may be able to ease the burden of medical care by utilizing Medicare-covered telehealth services, which can allow you to meet with your doctor via an internet-connected device. You can also see if you qualify for the Programs of All-Inclusive Care for the Elderly (PACE), a joint Medicaid and Medicare program that helps seniors receive care at home and in the community.
Another type of care that can fall under the home health care category, but covers a broader range of services, is called hospice care.
Another type of care that can fall under the home health care category, but covers a broader range of services, is called hospice care. To qualify for hospice care, you must be certified by your doctor to be terminally ill (a life expectancy of six months or less), though you can continue to receive care if you outlive your life expectancy. Finally, you can also find a stand-alone long-term care insurance plan that can cover the services that fall under “custodial care.”
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Home health care can be extremely beneficial for the millions of seniors who need it, but like any health care service, these services can be pricey as the costs add up. With Medicare insurance coverage, many find it much more possible to receive this care, but these services are only covered under specific conditions. Knowing these conditions and your alternative options can help you to be more informed and receive the help you need.