Does Medicare Advantage plans cover in home care?

Based on a recent Kaiser Family Foundation analysis, approximately 1 in 10 Medicare Advantage members are in a plan that covers some form of in-home support services. So, does Medicare Advantage plans cover in home care? This guide explores the different types of in-home care and explains how coverage can vary dramatically from plan to plan.

Quick Summary

Yes, Medicare Advantage plans must cover medically necessary home health care, just like Original Medicare, but may offer different costs, network rules, or require prior authorization. Some plans also offer extra, non-skilled in-home support benefits not covered by Original Medicare.

Key Points

• Skilled vs. Non-Skilled Care: Medicare Advantage plans are legally required to cover medically necessary skilled home health services, but non-skilled care is an optional supplemental benefit.

• Check Your Plan Details: Always review a specific plan's Summary of Benefits to see if supplemental benefits like non-skilled in-home support are included.

• Network and Authorization Rules: MA plans may have network restrictions for providers and require prior authorization for services, unlike Original Medicare.

• Eligibility Requirements: Medically necessary home health coverage requires a doctor's order and for you to be certified as homebound.

• Understand the Costs: While Original Medicare covers skilled home care at no cost, some MA plans may charge copayments for these services.

• Look Beyond Basic Coverage: Some MA plans offer extra benefits like meal delivery, transportation, and telehealth that can significantly enhance in-home support.

Understanding the Fundamentals of Medicare In-Home Care

Medicare coverage for care received at home is divided into two primary categories: skilled home health care and non-skilled in-home support. The distinction between these types of care is crucial for understanding what is covered by your plan.

Medically Necessary Home Health Care

By law, every Medicare Advantage (MA) plan must cover the same medically necessary home health care services as Original Medicare (Parts A and B). To qualify, you must meet specific criteria, including being certified by a doctor as homebound and needing intermittent skilled nursing care or therapy services.

Services covered under this benefit typically include:

• Intermittent Skilled Nursing Care: This is care that requires a licensed professional, such as wound care, injections, or monitoring of a serious illness. It is provided on a part-time, not 24/7, basis.
• Physical, Occupational, and Speech Therapy: These services are covered if a doctor determines they are medically necessary to restore function or safely maintain your current condition.
• Home Health Aide Services: These services, which assist with daily living activities, are only covered if you are also receiving skilled nursing or therapy services at the same time.
• Medical Social Services: Covered to help with social and emotional concerns related to your illness, such as counseling or finding community resources, but only if also receiving skilled care.
• Durable Medical Equipment (DME): Walkers, wheelchairs, hospital beds, and other supplies are covered under Part B, subject to a 20% coinsurance after the deductible.

Supplemental In-Home Support Services

This is where Medicare Advantage plans truly diverge from Original Medicare. Since 2019, MA plans have been permitted to offer supplemental benefits for non-skilled, non-medical services designed to help members live more independently at home. These benefits are not guaranteed and vary greatly depending on your specific plan and location. Examples of these supplemental in-home support services (IHSS) include:

• Light housekeeping
• Meal planning and preparation
• Assistance with activities of daily living (ADLs) like bathing, dressing, and toileting
• Coordination of transportation
• Companionship services

These benefits are provided by caregivers, not skilled nurses, and are not tied to the same "homebound" status required for medically necessary care. It is important to note that if a plan offers IHSS, there will likely be limits on the number of hours provided per year.

Medicare Advantage vs. Original Medicare: An In-Home Care Comparison

When considering your in-home care options, it's helpful to compare how Medicare Advantage plans handle coverage versus Original Medicare. While they must cover the same core skilled care, their rules and costs can differ significantly.

Feature	Original Medicare	Medicare Advantage (Part C)
Medically Necessary Home Health Care	Covered at 100% (you pay nothing for covered services).	Required to cover at least the same level, but may have different costs (e.g., copayments).
Non-Skilled In-Home Support (IHSS)	Not covered.	Some plans offer these as a supplemental benefit, with specific limits.
Network Restrictions	Almost all doctors and home health agencies accept Original Medicare.	Many plans are HMOs, requiring you to use in-network providers to get covered services.
Prior Authorization	Generally not required for standard home health benefits.	Many plans require prior authorization from the plan before services can begin.
Length of Stay & Visits	Studies have shown patients with Original Medicare often receive more visits and longer lengths of stay.	Studies indicate MA patients may have shorter home health stays and fewer visits.
Out-of-Pocket Costs	For durable medical equipment (DME) you pay 20% coinsurance after meeting the Part B deductible.	Costs for services and DME vary by plan and network, but plans have a yearly out-of-pocket maximum.

Important Considerations for Finding Coverage

Finding the right plan for your in-home care needs requires careful research. Here are several factors to consider:

Check for Specific Supplemental Benefits

If you anticipate needing non-medical assistance with daily tasks like bathing or meal prep, you must review the Summary of Benefits for each plan you are considering. Do not assume these benefits are included, as they are not standard across all plans.

Understand Network Rules

If your doctor recommends a specific home health agency, check if it's in your potential MA plan's network. With some plans, using an out-of-network provider may result in significantly higher costs or no coverage at all.

Know the Costs and Authorization Process

Be aware of potential copayments for home health services and the process for prior authorization. Missing a step in the authorization process can lead to denial of coverage and unexpected out-of-pocket costs.

Look for Value-Added Features

Beyond the core and supplemental benefits, some MA plans offer other features designed to support aging in place. These might include telehealth services, meal delivery after a hospital stay, or transportation to medical appointments.

What to Do If Coverage Is Denied

If your Medicare Advantage plan denies coverage for home health care you believe is medically necessary, you have the right to appeal the decision. Your plan should provide you with a written notice explaining the denial and outlining the appeals process. It is advisable to work with your doctor and a State Health Insurance Assistance Program (SHIP) counselor to navigate the process.

Conclusion: Navigating Your Options

Navigating the complexities of Medicare Advantage plans and their in-home care benefits requires diligence. While skilled, medically necessary care is a standard offering, the availability of non-skilled home support as a supplemental benefit is what truly sets different plans apart. By carefully comparing plan details, understanding the distinction between skilled and non-skilled care, and knowing your eligibility requirements, you can find a plan that best supports your needs for staying safe and comfortable at home. For more detailed information, consult the official guide on Home Health Services Coverage from the government [visit https://www.medicare.gov/coverage/home-health-services].

Frequently Asked Questions

What is the difference between home health care and in-home care?

Home health care refers to medically necessary services, like skilled nursing or physical therapy, typically covered by Medicare. In-home care, or custodial care, refers to non-medical assistance with daily tasks, which is only covered by some Medicare Advantage plans as an optional, supplemental benefit.

Does being homebound affect Medicare Advantage in-home care coverage?

Yes, to receive coverage for medically necessary home health care, a doctor must certify that you are homebound. However, supplemental non-skilled in-home support benefits often do not have this requirement.

Do all Medicare Advantage plans offer non-skilled in-home care benefits?

No. While MA plans can offer these as supplemental benefits, they are not required to do so. The availability and specific services offered vary by plan. You must check the plan's details to confirm coverage.

How do I find out if my Medicare Advantage plan covers in-home support?

You should contact your plan provider directly or review your plan's Summary of Benefits document. This is the only way to know for certain what specific services are covered and if there are any limits.

What if my doctor is not in my Medicare Advantage plan's network for home health?

If you are in an MA plan with a restricted network (like an HMO), you may need to find a different home health agency that is in-network. Going out-of-network could mean you pay the full cost of care, unless your plan makes an exception.

Will Medicare Advantage pay for 24/7 in-home care?

No. Both Original Medicare and Medicare Advantage generally do not cover 24-hour-a-day skilled or non-skilled care at home. The coverage for skilled care is intermittent and part-time.

What are the costs for in-home care with a Medicare Advantage plan?

Costs can vary. For medically necessary home health, some MA plans may charge a copayment per visit. For supplemental non-skilled care, the costs and limits are determined by the specific plan. You should clarify all potential costs with your plan provider.