Is Home Care Covered by Medicare?

Q. My sister, Betty, is 68 years old and has Parkinson’s disease. Her symptoms include tremors, impaired balance, difficulty walking and talking, anxiety, and confusion, at times. Her limited mobility makes it difficult for her to leave the home for the physical and occupational therapy services that she needs.

A skilled nursing facility is not the appropriate setting for Betty at this time, in my opinion, but it likely will be in the future. What we do need is a visiting nurse and therapists to assist with her needs. Could any of this home care be covered by Medicare? And will Medicare ever cover her if she needs long-term care in a nursing facility?

Thanks for your help!

A. Many health care treatments that were once offered only in a hospital or a doctor’s office can now be done in your home. Where possible, home health care helps you get better, regain your independence, and become as self-sufficient as possible. Home health care may also help you maintain your current condition or level of function, or to slow decline. Right now, Medicare covers some home health care, and these services are being expanded this year under certain Medicare advantage plans.

Every day, more seniors become dependent on home health care to maintain a normal and healthy standard of living. Home care helps those with debilitating diseases who are still able to be at home, and for those who have recently been hospitalized and are recovering, it helps ensure that they can stay safely at home while avoiding unnecessary re-hospitalizations. To understand home health care and how it can help in your situation, it’s necessary to know what home care entails and what is actually covered by Medicare.

Why is Home Care Important?

Home care offers numerous benefits such as:

1. Assisting with activities of daily living (ADLs). Seniors who are not capable of carrying out ADLs such as bathing, dressing, feeding, and toileting on their own are able to maintain a higher quality of life with assistance with these basic daily activities.
2. Preventing unnecessary hospitalizations of seniors. Home care providers are tasked with reminding seniors to take their medications on time and also ensuring that the home environment is set up in a way to prevent falls–the leading cause of injury and hospitalization for seniors.
3. Supporting independence at home. By enabling seniors to age at home, which is what the majority of seniors say they want, home care provides the requisite care they need while comfortably remaining at home.
4. Lowering costs. By allowing seniors to age in place, home care often provides a cheaper alternative to assisted living or nursing facilities.

Medicare pays for you to get health care services in your home if you meet certain eligibility criteria and if the services are considered reasonable and necessary for the treatment of your illness or injury.

Who’s eligible for Medicare-Covered Home Care?

If you have Medicare, you can use Medicare’s home health benefits (usually limited to 3 weeks of very intermittent coverage) if:

  • You’re under the care of a doctor, and you’re getting services under a plan of care established and reviewed regularly by a doctor.
  • You need, and a doctor certifies that you need, one or more of these:
    • Intermittent skilled nursing care (other than drawing blood)
    • Physical therapy
    • Speech therapy
    • Occupational therapy
  • The home health agency caring for you is approved by Medicare (Medicare certified).
  • You’re homebound, and a doctor certifies that you’re homebound.

Please note that if you’re expected to need full-time skilled nursing care over an extended period of time, you wouldn’t usually qualify for home health benefits.

Medicare may extend the three-week limit in exceptional circumstances if your doctor can predict when your need for daily skilled nursing care will end.

Home Care is Now Included in Some Medicare Advantage Plans

In the past, traditional Medicare or Medicare Advantage (MA) plans were never allowed to cover “daily maintenance” types of care, but that standard has now been relaxed. Starting this year, private-sector insurance companies that administer Medicare Advantage plans will be allowed to cover certain types of non-skilled in-home care. What will actually be covered under any given plan remains to be seen, and the cost of these additional services in the form of additional premiums also remains to be seen.

In the announcement about the expanded Medicare Advantage services, CMS stated, “As a part of these changes, CMS is redefining health-related supplemental benefits to include services that increase health and improve quality of life, including coverage of non-skilled in-home support, portable wheelchair ramps and other assistive devices and modifications when patients need them.”

Ultimately, for an aging population, the new Medicare Advantage rules mean lowering risk and enabling our seniors to age happy and healthy at home for as long as possible.

Where to go if you have Questions about Medicare Home Care Benefits
If you have questions about your Medicare home health care benefits or coverage and you have Original Medicare, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. If you get your Medicare benefits through a Medicare Advantage Plan or other Medicare health plan, call your plan. You may also call the State Health Insurance Assistance Program (SHIP). SHIP counselors answer questions about Medicare’s home health benefits and what Medicare, Medicaid, and other types of insurance pay for. In Virginia, call the Virginia Insurance Counseling & Assistance Program (VICAP) at 1-800-552-3402 or visit https://www.vda.virginia.gov/vicap.htm. In Maryland, contact the State Health Insurance Assistance Program (SHIP) at 1-800-243-3425 or visit http://aging.maryland.gov/Pages/StateHealthInsuranceProgram.aspx. And, in DC contact the Health Insurance Counseling Project (HICP) at 202-727-8370 or visit https://dcoa.dc.gov/service/health-insurance-counseling.

Medicare (or Medicare Advantage plans) Still Does Not Cover Nursing Home Long-term Care

Even with the new benefits and changes described, one thing remains the same: Medicare does not pay one penny, ever, for nursing home long-term care (also called custodial care), if custodial care is the only care needed (most nursing home care is custodial care) — see https://www.medicare.gov/coverage/long-term-care.

Medicare pays for health care for people age 65 years and older, people under age 65 with certain disabilities, and people of all ages with end-stage renal disease. Medicare only covers medically necessary care and focuses on acute care, such as doctor visits, drugs, and hospital stays. Medicare also covers short-term care and rehabilitation, such as physical therapy to help you regain your function after injuries such as a fall or a stroke. More of these short-term care and rehabilitation services can now be provided at home by MA plans under the new rules, but this is still short-term care, not long-term care.

For long-term care, the main government benefit is Medicaid, but Medicaid laws are the most complex laws in existence. There are strict financial requirements that must be met in order to qualify for Medicaid, including the requirement of having less than $2,000 of countable assets to your name. Nevertheless, with proper Medicaid asset protection planning, almost everyone can qualify for Medicaid when needed, without having to go broke by first spending down your life savings. If you or a loved one is nearing the need for long-term care or already receiving long-term care, please call us to make an appointment for a no-cost initial consultation:

Medicaid Planning Attorney Fairfax: 703-691-1888
Medicaid Planning Attorney Fredericksburg: 540-479-1435
Medicaid Planning Attorney Rockville: 301-519-8041
Medicaid Planning Attorney DC: 202-587-2797

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