Individuals recuperating from an illness or injury may wish to consider the convenience of in-home care. However, they may be unsure whether they can afford such services. For those enrolled in the Medicare program, the relevant question is: Does Medicare pay for home care? If so, what types of services does Medicare cover?
Who Does Medicare Cover?
Approximately 52 million people are currently enrolled in Medicare. Nearly 10 million of these individuals are disabled beneficiaries, and the remaining 42.5 million are 65 years of age or older. For these enrollees, Medicare Part A and Part B will cover some but not all home health services—and only if they have a doctor-established plan of care.
“There’s a misconception among beneficiaries and families that Medicare is going to pay for more than it does,” says Jeffrey S. Pine, MS, MSPH, CMC, founding director of EGIS Care and Support LLC in Santa Fe, N.M.
Pine, who currently serves as president of the Aging Life Care Association (formerly the National Association of Professional Geriatric Care Managers), explains that Medicare will pay for part-time skilled nursing care or therapy services during a recuperative period. While Medicare does not cover 24-hour-a-day at-home care (considered by the program to be custodial care), it will cover home health aides to help with bathing once a plan of care is established.
“Medicare home care typically comes when there is a change in a person’s medical status—for instance, at the end of a hospitalization or because a new development has altered the individual’s functional level and would benefit from clinical skilled care at home,” Pine says.
In order to be eligible for home health services under Medicare Part A or B, the individual must be under the care of a doctor and the required services must be outlined in a plan of care that the doctor establishes and reviews regularly. The doctor also must certify that the individual is homebound.
“The individual can leave the home for a doctor’s appointment, but not for recreational purposes,” Pine explains. “Once the person leaves the home for an independent outing such as going to the movies, they are no longer homebound. They would still be able to receive therapy services for a period of time under Medicare as an outpatient, but Medicare would no longer pay for in-home care.”
One non-medical exception to this rule is that Medicare does permit individuals to attend religious services. Additionally, those who attend adult day care are still eligible for health services at home.
Medicare Home Health Care Benefits
The doctor’s plan for Medicare-covered in-home care must certify that the individual requires one or more of the following services for a finite period of time: physical therapy, occupational therapy, speech-language pathology and/or intermittent skilled nursing care. The home health agency providing the services must be Medicare-certified.
“When there is a documented need for skilled care, the home care companies can send home health aides who can assist the individual with bathing and other personal care tasks as part of their capitated rate” Pine says. “But Medicare will not pay for these individuals to come into the home for personal care needs alone.”
In addition, Medicare covers in-home hospice services for those with a life expectancy of no more than six months. “This gives the individual 24-hour on-call nursing and physician support,” Pine says. “However, hospice is provided with the understanding that the services are palliative, not curative. Hospice sends in-home health aides to provide intermittent help with bathing and personal care as well as nurses who address the issues of pain management and comfort. The amount of knowledge that these individuals have to improve the quality of life is amazing.”
Limitations to Medicare Home Care Benefits
It’s important to note that the Medicare home health benefit does not cover more than part-time or intermittent care. For those requiring full-time care after a qualifying hospital stay, Medicare will provide coverage for a specified period at a skilled nursing facility or rehabilitation center.
Pine sees some advantages of going into a skilled nursing or rehab facility versus in-home care. “In the home, a physical therapist might come two or three times a week for no more than an hour or hour and a half. At a rehab facility, the individual has access to physical therapy one or more times each day and also receives personal care.”
While Pine acknowledges the strong desire that individuals have to return to the comfort of their homes, the cost can be significantly higher when figuring in incidental care not covered by Medicare. “I advocate going to a rehab facility for a specific period—such as a 10 days to two weeks—so that you’ll be stronger and need less care when you do go home.”
Keep in mind that family caregivers can play a role in augmenting the Medicare-covered home care provided by skilled nursing and therapy professionals. “Eventually caregivers become adept at helping their loved one,” Pine says. “I find that what people need are cheerleaders, motivators—individuals who can cajole them into doing the exercises that will help them get better.”