If an illness or injury gets in the way of your daily life, in-home health care can be a good option. Getting care at home can help you feel better, teach you new ways to take care of yourself, or prevent your health from getting worse.
Based on what you need and why, Medicare may pay for some of your care.
Figuring out the details can take some time (and be confusing), but don’t worry. “You’re not on your own,” says Casey Schwarz, senior counsel of education and federal policy at the Medicare Rights Center in Maine. “Your home health agency, doctor, physical therapist, or nurse practitioner will be able to explain your options and help you through it.”
What Medicare Covers
“The very first thing patients and caregivers have to understand is how you’re getting your benefits,” says Tatiana Fassieux, an education and training specialist for California Health Advocates.
Medicare A (hospital insurance) and Medicare B (medical insurance) are offered either by the federal government through a program called Original Medicare, or through a private insurer as a Medicare health plan.
Both types pay for home health care like:
- Part-time or occasional skilled nursing (care that can only be given by a registered nurse or licensed nurse practitioner)
- Part-time or occasional personal hands-on care (like help going to the bathroom, getting dressed, or bathing)
- Physical therapy (learning to move or strengthen a body part or getting help using special medical equipment)
- Occupational therapy (learning new ways to do daily tasks, like feeding yourself, without extra help)
- Speech-language therapy (learning or strengthening how well you can talk)
- Social services (like counseling or finding local support)
Some home medical supplies and equipment (like blood sugar meters, crutches, and hospital beds) may also be covered by Medicare.
What Medicare Doesn’t Cover
Medicare A and B won’t pay for:
- 24-hour home care
- Meals brought to your home
- Prescription drugs
- Home chores like cleaning, shopping, and laundry
- Personal care (like bathing, dressing, or taking you to the bathroom) when it’s the only help you need
Needing help around the house — but not skilled care — “is an issue that comes up a lot for folks,” Schwarz says. “Sometimes, we get calls from someone who, because of physical limitations, needs help with housekeeping, changing bed linens, doing laundry, and cleaning their kitchen. Those things can have an impact on your health, but they’re not services that can only be done by skilled professionals, like a nurse or physical therapist.”
If you only need help around the house, Medicare won’t pay, but Medicaid or long-term care may be able to help, Schwarz says.
How to Get Home Health Care
To start home health care, your doctor will have to prove to Medicare that one or more of the following apply to you:
- You need skilled nursing care
- You need physical therapy, speech therapy, or occupational therapy
- You’re homebound (You have trouble leaving home without help or it takes a major effort)
“Some rules are slightly changed as a result of the pandemic,” Schwarz says. “For instance, the definition of ‘homebound’ is broadened. Your health care team could state that it’s not advisable that you leave home right now.”
Choosing a Home Health Care Agency
The next step is to find a home health care agency to provide you services. Here’s where the type of Medicare you have matters.
- If you have a Medicare health plan, you’ll need to choose an agency that has a contract with your plan. Otherwise, Medicare might not pay the bill.
- Original Medicare lets you use any agency as long as it’s Medicare-certified (they meet Medicare’s standards)
If your doctor can’t suggest an agency, you can look at online ratings and compare.
How Medicare Pays for Home Health Care
Before you start care, your home health care agency should tell you:
- How much Medicare will pay
- How much you’ll pay out-of-pocket if any service or item isn’t covered.
Original Medicare will pay the full approved cost of all covered home health care visits. You could be charged 20% of the cost of any medical equipment.
To figure out what your Medicare health plan will pay, you’ll need to contact your insurer. All plans are different, so “read those co-pays,” Fassieux says.
Your doctor and home health care agency will review your care at least every 60 days. The type of services you get or equipment you need may change, based on how you’re doing, but Medicare should pay for as long as you’re eligible.
If Medicare denies your request for help or won’t pay for something that you think they should, you can file an appeal.
Where to Get Help
“The Medicare handbook is sent to everyone, regardless of how you’re getting services,” Fassieux says.
Look for a copy in the mail every fall that you’re signed up for Medicare. Inside, you’ll find a section about home health care services.
Free one-on-one help is also available in every state and U.S. territory through your State Health Insurance Assistance Program (SHIP). You’ll find contact info for your local office in the Medicare handbook or call 1-800-MEDICARE (633-4227)/TTY: 1-877-486-2048.
The bottom line? “Medicare doesn’t cover everything,” Fassieux says. “You’ve got to have a good plan for long-term care. Build your finances around the knowledge that ultimately there will be out-of-pocket costs.”