Medicare is the health insurance of choice for nearly 20% of Americans, covering more than 63 million older adults. Depending on the plan, Medicare covers a wide variety of services from doctor’s visits to prescription drugs, but many seniors may require in-home care or home health care at some point during their coverage period—and many are left wondering if Medicare covers this important service.
The short answer is yes. Medicare does cover in-home care—but only in certain circumstances.
Who qualifies for Medicare home health services?
Medicare will cover a variety of in-home care if certain qualifications are met. To receive benefits under the home health care portion of Medicare, a senior needs to meet the following criteria:
- They are under the care of a doctor, and that doctor has developed a plan of care that includes home health services. The medical team, including the doctor, must review the plan of care at least every 60 days.
- They are homebound. In-home health care is only available to Medicare recipients who have been documented as homebound by a doctor.
- A doctor has certified you need intermittent skilled nursing care or physical therapy, occupational therapy or speech-language pathology services. According to Medicare.gov, these services must be “specific, safe and an effective treatment for your condition. The amount, frequency and time period of the services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively.”
What’s covered under the Medicare home health benefit?
If you meet the criteria to qualify for in-home care, Medicare covers a wide variety of services. You may be eligible for some or all of them, depending on what your doctor requests.
Covered home health services under Medicare include:
- Part-time or “intermittent” skilled nursing care
- Physical therapy
- Occupational therapy
- Speech-language pathology services
- Medical social services
- Part-time or intermittent home health aide care – This benefit only applies if you are also receiving skilled services.
- Injectable osteoporosis drugs for women
- Durable medical equipment – Medicare generally covers 80% of durable medical equipment.
- Medical supplies for use at home
What’s not covered under the Medicare home health benefit?
While Medicare’s coverage for in-home care includes a broad swath of services, some services aren’t covered:
- A home health aide to help with personal care unless you’re also receiving skilled nursing or therapy services
- 24-hour in-home care
- Meal delivery
- Household services like shopping, cleaning and laundry not related to your care plan
If your senior needs assistance with meals, personal services or 24-hour care, you’ll need to look at other options to meet their needs.
Many communities have a Meals on Wheels service that provides meals to homebound seniors. A senior’s local religious community may be able to provide household services like cleaning and shopping, or you can hire someone to help with these tasks.
If a senior needs 24-hour care – and if they qualify – Medicaid may pay for them to live in a skilled nursing facility. Some private long-term care insurance policies may also have a provision for in-home health care as well as nursing home care.
How do I coordinate home health services?
To use home health services with your Medicare plan, you’ll need to have those services delivered by a Medicare-approved provider.
Often, your doctor will help you coordinate care through a Medicare-approved home health service. Check with your doctor to see if they have a service they prefer to work with.
What if I don’t qualify for in-home care through Medicare?
If you need in-home care but you don’t meet the criteria to be eligible through Medicare, you may have other options:
- Check with your state to see if they have any aid programs your loved one is eligible to use.
- Check any long-term care policies the senior owns to see if they cover in-home health care.
- Investigate any programs offered by private social services organizations in your area.
- Contact the senior’s local religious community to see if they can provide help.
- Consult with your doctor to see if any of the services like therapy can be provided in the office where Medicare might cover them.
Medicare benefits and requirements can sometimes be confusing, so it’s important to understand what your loved one is eligible for before services start. Work closely with their physician to make sure you know what’s being prescribed so you can understand any costs to the senior before a care plan is put into place.