Medicare, the government insurance program for seniors, provides coverage for various health care needs and services. However, coverage for some services often comes with strict requirements. Home health services are one example.
Medicare Part A and B, which provide hospital and medical insurance, cover eligible home health services. However, it’s important to understand what services are available before you seek these benefits.
Meanwhile, Medicare Advantage, also called Part C, offers more flexible benefits and you may find a plan that provides more home health services.
Here’s what you should know about Medicare and home health care.
Does Medicare cover home health care?
You may need home health services to address an acute health need, such as recovery after hip surgery. Or you might require it for rehab after a heart attack. This care can be expensive, especially if a senior is retired or is no longer able to work.
Medicare Part A and B, also called Original Medicare, covers home health services, such as medical social services, part-time skilled nursing care, physical and occupational therapy, a part-time home health aide and speech therapy.
However, a Medicare beneficiary needs to meet conditions to have home health care services approved, says Mike Sheeran, a certified financial planner and account executive at Glenn Insurance, an independent insurance agency based in New Jersey.
“This list isn’t exhaustive, but to qualify, you need to be under a doctor’s care and the doctor must certify that you need intermittent skilled care. Your condition must be improving or be expected to improve in a reasonable amount of time and you must be homebound. If your doctor can’t certify your conditions meet the criteria, the claim will be denied, unfortunately,” says Sheeran.
Sheeran adds that “diseases that don’t have a good prognosis for improving over time likely won’t be covered by Medicare or the benefits may not be what you expect.”
Medicare doesn’t pay for some homebound services, including:
- Around-the-clock care
- Meal delivery
- Most drugs if you’re homebound (except injectable osteoporosis drugs for women)
- Housekeeping services
- Personal care services — such as help with bathing and getting dressed — if that’s the only care you need
Who’s eligible for home health care covered by Medicare?
To be eligible for home health care, your doctor must certify that you’re homebound.
Medicare’s definition of homebound includes:
- Difficulty leaving your home due to a health issue
- Need another person’s help or need to use medical equipment, such as a wheelchair or walker, to be mobile enough to leave your home
- Need skilled services for your care
- Receive services under a care plan created or reviewed by a doctor and have seen a doctor or another qualified medical professional face-to-face before seeking home health care benefits
There’s an appeal process if Medicare denies the home health care benefit. Your provider can help you with the appeal.
“Sometimes, more information is needed before a service can be approved or there may be another issue that needs addressing,” Sheeran says. “When dealing with home health care specifically, there can be situations where your covered expenses are ending sooner than you think they should. In these cases, there is a process for an expedited appeal.”
How much does Medicare pay for home health care per hour?
Home health services can be expensive.
The 2019 Home Care Costs and Affordability Index estimated that home health care costs $21 an hour, on average, in the U.S. The care’s cost varies depending on where you live. For example, home health care costs are on the lower end in Louisiana at $16 an hour. In Washington state, they are 75% more — at $28 an hour.
You must seek the services of a Medicare-certified home health agency to get home health care benefits. After this, Medicare will pay for covered services for 60 days. Medicare bases its payments on your condition and care needs.
As Sheeran mentions, if you need services for a longer time, you have a right to a fast appeal in which an independent reviewer will assess your case and decide whether your services should continue beyond the 60-day period.
What does Medicare Advantage cover?
More than one-third of Medicare recipients have a Medicare Advantage plan rather than Original Medicare. These plans, offered by private insurers, can have added benefits, including home health care benefits, which aren’t found in Original Medicare.
Medicare Advantage plans must provide at least the same coverage level as Original Medicare, but benefits differ by plan. It’s vital to review each plan’s benefits and to understand the home health benefits your plan offers — and at what level — when comparing Medicare Advantage plans.
One major difference to Original Medicare is that Medicare Advantage plans may cover custodial care, such as bathing, dressing, eating, transferring and using the restroom. If you want that kind of home health coverage, make sure the Medicare Advantage plan covers it before signing up.
Home health benefits can be a godsend for many Medicare beneficiaries. However, if you aren’t 65, it’s important to start making a plan for your long-term care. This may include long-term care insurance or hybrid life long-term care insurance policies, depending on what you can afford.
“It’s important to consider all the possible outcomes when planning for your healthcare as you age and many should consider looking at long-term care insurance as a supplement to cover things like custodial care and assistance at home,” Sheeran says.