Medicare Home Health vs. Non-Medical Home Care
Understanding whether Medicare pays for in-home assistance starts with a crucial distinction between two types of care: home health care and non-medical home care.
Home Health Care (Medically Necessary)
This refers to skilled medical services ordered by a doctor to treat an illness or injury. Medicare does cover this category of care for eligible seniors, provided by a Medicare-certified home health agency on a part-time or intermittent basis.
Covered Home Health Services often include:
- Skilled nursing care and therapy services (physical, speech, occupational).
- Medical social services.
- Home health aide services for daily living activities, but only when also receiving skilled nursing or therapy.
- Durable medical equipment (DME), subject to a 20% coinsurance after the Part B deductible.
- Medical supplies provided by the home health agency.
Non-Medical Home Care (Custodial Care)
This involves non-skilled, personal care or homemaker services. Medicare generally does not cover these services unless combined with medically necessary home health care.
Commonly Excluded Services:
- 24-hour-a-day care
- Long-term personal care when it is the sole need
- Homemaker services
- Home-delivered meals
Medicare Eligibility for Home Health Coverage
To qualify for Medicare home health benefits, you must meet specific criteria and have a plan of care from your doctor.
Key eligibility criteria:
- Homebound Status: Certified by your doctor, meaning it's difficult to leave home, though exceptions exist for medical appointments, religious services, or adult day care.
- Need for Skilled Services: Certified need for intermittent skilled nursing, physical, speech, or occupational therapy.
- Medicare-Certified Agency: Care must be from a Medicare-certified agency.
- Face-to-Face Visit: A provider must have a visit with you related to your need for home health services before care begins.
Comparing Medicare and Medicaid Home Care Benefits
Comparing Medicare with Medicaid is important for understanding home care coverage, as Medicaid is for individuals with limited income and resources.
| Feature | Medicare | Medicaid (varies by state) |
|---|---|---|
| Primary Purpose | Federal health insurance for seniors 65+ and certain disabled individuals. | Joint federal and state program for low-income individuals. |
| Home Health Care (Skilled) | Covers part-time/intermittent skilled nursing and therapy if homebound. | Typically covers skilled home health services. |
| Personal/Custodial Care | Does not cover long-term personal care if it is the only service needed. | Often covers personal care and assistance with activities of daily living. |
| Long-Term Care | Does not cover most long-term care services. | Can cover long-term home and community-based services, depending on the state. |
| Eligibility | Age 65+ or certain disabilities, regardless of income. | Limited income and resources, with varying state requirements. |
| Out-of-Pocket Costs | Generally, $0 for covered home health services, but 20% coinsurance for DME applies. | Very few or no out-of-pocket expenses for covered services. |
Alternatives for Funding Long-Term Home Care
Since Medicare's home care benefits are limited to medically necessary services, other options exist for long-term personal care.
- Medicaid Home and Community-Based Services (HCBS) Waivers: State programs using Medicaid can offer a broader range of in-home services.
- Long-Term Care Insurance: Private policies can help pay for non-Medicare covered home care.
- Veterans' Benefits: VA benefits like Aid and Attendance may assist eligible veterans and spouses with in-home care costs.
- Private Pay: Using personal funds is an option if other programs don't apply.
- Medicare Advantage (Part C): Some plans may offer limited coverage for certain non-medical home care services; check plan specifics.
Conclusion
Medicare covers short-term, medically necessary home health care but not long-term personal or custodial care. Seniors and their families should understand these limits and explore alternatives like Medicaid, long-term care insurance, or Veterans' benefits for comprehensive home care needs. The distinction between medical home health care (covered by Medicare) and non-medical home care (generally not covered) is key.
