by: The My Medicare Matters Team
Experiencing a health emergency like an injury from a fall, or even a heart attack, typically occurs unexpectedly. While these and many other acute conditions only last for a short period of time, the road to recovery may require additional assistance like in-home care. The good news is that Medicare can provide home health care (HHC) services to help you recover.
Home health care is meant to provide health services and equipment to individuals while they are homebound. Unfortunately, Medicare does not cover custodial care, or long-term care, often required for those diagnosed with Alzheimer’s, cancer, and many other conditions. There are programs available that provide long-term care and assist with the cost.
1. To qualify for home health care, you must meet the following criteria:
- Be considered “homebound,” based on the Centers for Medicare & Medicaid (CMS) criteria,
- Require skilled care on a part-time or intermittent basis to improve, maintain, prevent, or further slow your health condition,
- Be under the care of a doctor, who completes and documents an in-person visit with you either:
- three months before the start of HHC, or
- within one month after the HHC benefit has begun.
- Receive HHC from a Medicare-approved home health agency.
But what exactly does that mean? Well, let’s say you end up in the hospital after a fall and get surgery on your knee. After spending at least 3 days in the hospital it’s time to get discharged, but you have not completely healed from your injury. The discharge documents from your physician will include information about you being homebound and needing short-term skilled care. The documents will also include a plan of care that notifies Medicare and health care agencies of the services and equipment you will need while being cared for. Once this happens you are now eligible to receive home health care from a Medicare-approved agency.
2. Medicare only covers care for specific services
If you are eligible for home health care you can receive skilled nursing care and rehabilitative care from approved home health care services. These services include physical therapy, occupational therapy, speech-language pathology services, medical social services, durable medical equipment, medical supplies, and other services provided in your home.
3. If you are enrolled in Original Medicare you pay nothing for home health care services
However, you may be responsible for 20% of the Medicare-approved amount for durable medical equipment. Cost and benefits may be different for beneficiaries enrolled in Medicare Advantage plans, so check with your plan to find out how they provide Medicare-covered home health benefits.
Ask the home health care agency about what services Medicare will pay for and what is not covered, as some agencies recommend services not covered by Medicare. Home health agencies must notify you of the cost of services in writing before starting care.
4. Custodial Care (Long-Term Care) is non-skilled personal care
Non-skilled personal care includes activities of daily living (ADLs) like bathing, dressing, eating, chores, and health-related care that most people do on their own, like taking insulin. Agencies that offer these services are referred to as home care agencies, not to be confused with home health care agencies which offer home health care services.
5. Medicare does not cover custodial care
If your care includes any of the following services: 24-hour care, meal delivery, homemaker services, personal care (unless it’s included with HHC plan) Medicare will not cover the cost. Medicaid sometimes pays for services to keep seniors in their homes. The services covered and requirements for enrollment vary by each state’s Home and Community Based Services program.
6. Some states offer custodial care programs for older adults
Programs like adult day care, chore assistance, and homemaker services are offered by some state Medicaid programs. Vouchers may also be available for low-income households who qualify.
If you need help locating these programs we recommend trying BenefitsCheckUp®, a free, online screening tool from NCOA. This tool screens for thousands of money-saving programs, including local respite care, adult day care, and state Medicaid programs. We also recommend contacting your local State Health Insurance Assistance Program (SHIP) for free, federally-funded Medicare counseling.
7. Home Health Care and Home Care comparison
Even with all this information, differentiating between home care and home health care can be confusing. Below is a chart to help highlight some of the major differences and similarities in services covered, enrollment requirements, and payment options.