Health care in retirement starts with Medicare, but Medicare is not where it ends. The fact is Medicare will only pay for a very specific and limited amount of home health care benefits.
We will go over what Medicare will cover, what they won’t, and other options you have to pay for home health care!
What does Medicare cover for home health care?
The Centers for Medicare & Medicaid Services lists what Part A and Part B will cover. This includes:
- Part-time or “intermittent” skilled nursing care
- Physical therapy, Occupational therapy, and Speech-language pathology services
- Medical social services
- Part-time or intermittent home health aide services
- Medical supplies
There are requirements you must meet in order for Medicare to cover the above. The most important one is that the care you need must warrant skilled nursing care.
Skilled nursing care means that you require a licensed and trained nursing professional. This care must be provided by a Medicare-certified home health care agency in order to get it covered.
The skilled nursing care must also only be needed on a part-time, or intermittent, basis. This means that you do not need care full time around the clock. Medicare limits intermittent care to mean that you either need help fewer than 7 days each week and for less than 8 hours a day.
These services, especially therapy services, are only going to be Medicare approved if the condition being treated is able to improve. These services must also be prescribed by a doctor, who then has to re-certify the plan every 60 days, as Medicare only approves care for a 60 day period.
Recipients also must be certified by a doctor as home bound. This does not mean that you have to be stuck in bed, but that it takes considerable effort to leave your home.
Home health aide services, social services, and medical supplies, and occupational therapy will only be covered when you are at home if they are paired with skilled nursing care. You cannot receive coverage for them if it is all you need.
What does Medicare not cover for home health care?
The main objective of Medicare when covering home health care is to provide beneficiaries with short-term skilled services as an alternative to recovering in a hospital or skilled nursing facility.
Once your needs pass this main objective, Medicare is not going to pay for this care. On Medicare’s site, they list the following as what they will not pay for:
- 24-hour-a-day care at home
- Meals delivered to your home
- Homemaker services (like shopping, cleaning, and laundry), when this is the only care you need
- Custodial or personal care (like bathing, dressing, or using the bathroom), when this is the only care you need
The most important point to take from this is if you need help with ADLs, or Activities of Daily Living, Medicare will not pay. Activities of Daily Living include eating, bathing, dressing, toileting, transferring, and continence.
To sum it up, if your condition is not short-term, does not need skilled care, and is not expected to improve, Medicare will not pay for it.
How much will home health care covered by Medicare cost me?
When you have Medicare Part A and Part B, or Original Medicare, this is usually going to pay for everything but 20% of your costs. If you have a Medicare Supplement, it is built to cover this 20%. This means you should have no out-of-pockets costs besides normal deductibles and copays for Medicare approved services.
If you are getting home health care services, the home health agency should go over what Medicare is going to pay and what they are not going to pay.
Doctors might recommend you get services more often than Medicare covers or services that Medicare just does not cover. The home health care agency should go over how much you will have to pay for them if necessary.
If Medicare doesn’t pay for home health care, how can I pay for it?
Like we mentioned, most people who want home health care are not going to qualify for Medicare coverage. They are going to have to pay for the bulk of the care out of pocket.
There are a few insurance options you can look at for covering these services, these include:
- Short term care insurance
- Traditional long term care insurance
- Hybrid long term care insurance
- Pre-pay home care options
All these options must be purchased before you need care. If you are in your 50’s, 60’s, or even 70’s, it is a great time to start looking into these to prepare.
If you are already needing care, there are still things that can be done. Cardinal specializes in creating a plan for self-insurance, specifically for home health care. We can help you or your loved one get a plan into place for how they want to receive care and how they are going to pay for it.