Does Medicare Pay for Home Care?
Yes, but people need to know about important limitations. When Americans plan for retirement or consider how they might manage an unforeseen disability, Medicare always plays a large role. Medicare pays for some very important home care services but does not pay for others. That’s why understanding what Medicare does and does not pay for is so important. In short, Medicare does pay for short-term and intermittent home health. Medicare does not pay for long-term home care. Medicare does pay for medical home health. Medicare does not pay for home care that is primarily non-medical. We’ll explore these differences and what they might mean to a retiree or a disabled adult below.
What Home Care Does Medicare Pay For?
Medicare includes benefits for medical home health. In fact, Medicare pays 100% when people qualify for home health. Medicare has no co-pays for home health, and Medicare waives any deductibles. When patients with Medicare need medical home health, patients have no cost sharing of any kind. This can prove extremely helpful when patients need stroke rehabilitation, rehabilitation for heart problems, help following doctor’s orders, etc.
So, what do they mean by “medical home health?” Medical home health means the main services being delivered require the expertise of a nurse, physical therapist, or speech therapist. Examples include wound care, reviewing medications, teaching a therapeutic diet, exercise planning, fall injury prevention, chronic disease management, etc. The “medical” home health distinction is meant to exclude service plans that are mostly about home care aide work. Home care aides help with walking, getting up and down, meal preparation, house cleaning, laundry, etc. Think of the difference between medical home health and non-medical home care as being like the difference between hospital care and staying at an assisted living facility.
A couple of exceptions exist. Medicare may pay for home care aide work under certain circumstances.
Exception One: if the purpose of home care is primarily for nursing or therapy, then home health agencies may send home health aides paid for by Medicare. When a person is recovering from a hip replacement, that home care aide service can mean the difference between staying in the nursing home or getting to go home.
Exception Two: starting in 2019, the Centers for Medicare and Medicaid Services (CMS) will allow Medicare Advantage Plans to use Medicare benefits to pay for non-medical home care that is primarily custodial in nature. Traditional Medicare, so far, has no plans to participate in this. It is unlikely that Medicare Advantage Plans will be able to adjust to the new rules by 2019, but we may see some non-medical home care coverage by major Medicare Advantage plans by 2020.
The Home Care that Medicare Does Not Pay For:
Understanding what home care Medicare will not pay for proves vital to each person’s and each family’s long-term planning. Bear in mind that legislators designed Medicare to be a hospitalization plan or health insurance. Health insurance pays when you are sick or injured. It typically excludes long-term care. Medicare does not pay for most forms of long-term care, whether the care requires a home care aide or a nurse. For example, if a family wanted to pay someone to go to a grandparent’s home and fill pill boxes every week, this would require a nurse. In most states, scope-of-practice laws prohibit home care aides from taking medicine out of bottles. Even though this home care plan requires a nurse, because it’s a long-term need, Medicare will not pay for this service plan.
Additionally, as stated above, Medicare usually does not pay for home care plans that focus mostly on non-medical services, even if the plans are temporary, and even if the plans are related to a recent injury or illness. Imagine a new mom returning home from the hospital after a very difficult labor. She may need someone to help with baths and homemaking during her recovery. Medicare would not pay for that, because the plan only includes home care aide work, not home health nurse work. Americans need to plan for non-medical home care knowing that Medicare will not pay for this service in many circumstances.