Medicare and Home Care
The Relationship between Medicare and Home Care Services
Medicare is a health insurance program for people:
- Who are 65 or older
- Who are younger than 65 with certain disabilities
- Who have End Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant)
Medicare Part A, covers Hospital Insurance, and Medicare Part B, includes medical insurance.
The Medical Insurance (Medicare Part B) covers eligible, recurring or occasional, home health services like skilled nursing, physical therapy, speech-language therapy, pathology services, occupational services and more.
Your doctor will order or prescribe home health care services, and the agency coordinates the care you need at home.
Medicare is a Federal Health Insurance Program
- Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
- Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.
- Advantage Plans is a type of health plan offered by private companies that contract Medicare to provide you with all your Part A and Part B benefits. Those are Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans.
- Part D adds Prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans offered by private companies and approved by Medicare.
What Part of Home Care Will Medicare Cover?
What types of home health services will Medicare cover at home?
- People who have Medicare get home health care services when they meet the following:
- A doctor determines your need for medical care at home and summarizes a plan for care.
- A person requires skilled nursing care, physical therapy, speech-language therapy, or on-going occupational therapy.
- A home health agency certified by Medicare will care for patients at home..
- The person is homebound. It means that leaving home is a major effort.
If a person need more that part-time or intermittent skilled nursing care, you're not eligible for home health care services in the home. You must move to a nursing home facility to receive skilled nursing care.
Medicare does not pay for:
- 24-hour-a-day care at home
- Meals delivered to your home
- Homemaker services
- Personal care
Top Medical Conditions that Receive Home Health Care
- Cardiovascular Disease
- Musculoskeletal and Connective Tissues
- Respiratory Disease
- Cancer and Tumors
- Endocrine, Nutritional, Metabolic and Immunity
What Services are Provided by Home Care
- Nursing Services
- Physical Therapy
- Social Services
- Homemaker Services
- Medication Management
- Occupational Therapy
- Physician Services
- Nutrition Services
Medicare Eligibility for Home Health Care
A person's permitted to leave the house for medical treatments or infrequent absences for non-medical reasons, for attending religious services.
You're allowed to get home health care if you attend adult day care.
Other home health services available:
- Medical social services
- Part-time or intermittent home health aide services
- Medical supplies for use at home
- Durable medical equipment
- Injectable osteoporosis drugs
Percentage of Home Care Agencies that Accept Medicare
It is difficult to determine exactly what percentage of home health care agencies accept Medicare because there is no complete nation-wide list of agencies. According to our data, approximately 30% of home care agencies in the U.S. are certified by Medicare. Realize that while Medicare provides a great deal of data about certain agencies, those agencies are also likely to be the type with trained nursing staff and therapists. If that isn't the type of care you or your loved one needs, be sure to examine all home care agencies in your area.
The Costs You Pay with Original Medicare
- $0 for home health care services
- 20% of the Medicare-approved amount for durable medical equipment
Ask the home health care agency how much Medicare pays, before commencement of home health services.
Ask if they'll give you services that are not covered by Medicare, and if they will, how much they'll charge you out-of-pocket for them. Get it in writing.
The home health agency should give you a notice called the "Home Health Advance Beneficiary Notice" (HHABN) before giving you services and supplies that Medicare doesn't cover. The form gives you directions for getting an official decision from Medicare about payment for home health services and supplies and for filing an appeal if Medicare won't pay. Read about HHABN.
To Get Help with Your Medicare Rights & Protections
Contact the Medicare Beneficiary Ombudsman to review and help with your Medicare complaint. They tell you how to get issues resolved. Medicare Beneficiary Ombudsman: 1-800-MEDICARE.
- Are you unclear about the kind of coverage you have?
- Check your red, white, and blue Medicare card.
- Check all other insurance cards that you use.
- Call the phone number on the cards to get more information about the coverage.
- Check your Medicare health or drug plan enrollment.
- Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
What to do Get an Official Medicare Decision on Payment
- Keep getting the home health services or supplies if you think you need them.
- The home health agency must tell you how much they will cost.
- Talk to your doctor and family about this decision.
- Understand you may have to pay the home health agency for these services and supplies, out-of-pocket.
- Ask the home health agency to send your claim to Medicare to decide if they'll pay.
- You have the right to have the agency bill Medicare.
If Original Medicare pays for your care, you'll get back all of your payments, except coinsurance or deductibles, even those paid to the durable medical equipment.
Things to Know When Choosing Medicare Coverage
Services: Does the plan cover the type of care I need?
If you have other types of prescription or health coverage, make sure you understand how that coverage works with Medicare. If you get health care from an Indian Health, Tribal Health Program or an employer, talk to your benefits administrator or insurer before making any changes.
How much are your premiums, deductibles, and other costs: hospital stays or doctor visits? Is there an annual limit on out-of-pocket medical services?
Doctor and hospital choice:
- Do your doctors accept the coverage and are they accepting new patients?
- Do you have to choose your hospital and health care providers from a network?
- Do you need to get referrals?
- Do you need to join a Medicare Prescription Drug Plan?
- Do you have a drug plan?
- Will you pay a penalty if you join a drug plan later?
- What's the plan's overall star rating? Are your drugs covered under the plan's formulary?
- Are there any coverage rules that apply to your prescriptions?
- Are you eligible for a free Medication Therapy Management (MTM) program?
Quality of care:
- Are you satisfied with your medical care?
- How have Medicare and other people with Medicare rated your health and drug plan's care and services?
- Get help comparing plans and providers.
- Where are the doctor's offices?
- What are their hours?
- Which pharmacies can you use?
- Can you get your prescriptions by mail?
- Do the doctors use electronic health records (EHRs) or E-prescribe?
- Can you get an electronic copy of your information by email or to store in a personal health record?
- Which pharmacies can you use?
- Is the pharmacy you use in the plan's network?
- If it's in the network and your plan has preferred pharmacies, is your pharmacy preferred?
- You may pay more at non-preferred pharmacies.
- Can you get your prescriptions by mail?
Travel: Will the plan cover you if you travel to another state or outside the U.S.?
After seven years of helping her aging parents, Carol Marak has become a dedicated senior care writer. Since 2007, she has been doing the research to find answers to common concerns: housing, aging and health, staying safe and independent, and planning long-term.
- What is Home Care?
- Home Health Care vs. Non-Medical Home Care
- Home Health Care Services
- Non-Medical Home Care Services
- How is Home Care Different from Other Care Options?
- When is Home Care Needed?
- Benefits of Home Care
- Talking to a Loved One
- Selecting a Home Care Agency
- Medicare Quality Data
- Hospice Care
- Home Care Safety
- Considering Home Care Staff
- Home Health Care Costs
- Ways to Pay for Home Care
- Medicare and Home Care
- Medicaid and Home Care
- Does Insurance Cover Home Care
- Using a Reverse Mortgage to Stay Home