March 14, 2018
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 careand 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.
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