What is HCPCS Code T1019 and what does it cover?
T1019 is a specific HCPCS (Healthcare Common Procedure Coding System) code used by providers to bill for “personal care services”. Specifically, it represents non-medical assistance with activities of daily living (ADLs), typically provided in 15-minute intervals. These are routine, non-skilled services that help an individual with everyday tasks.
Activities of daily living (ADLs) under T1019
- Bathing and grooming
- Dressing
- Feeding
- Help with mobility and walking
- Meal preparation
- Light housekeeping
It is important to note that T1019 explicitly cannot be used to bill for services provided by a home health aide or certified nurse assistant when they are acting as such. This distinction is critical because Medicare has separate, and different, rules for home health aide services.
Medicare's distinction between skilled care and custodial care
The primary reason Medicare does not pay for T1019 services is its fundamental distinction between skilled care and custodial care.
Skilled care vs. custodial care
| Feature | Skilled Care (Generally Covered by Medicare) | Custodial Care (Generally Not Covered by Medicare) |
|---|---|---|
| Definition | Care that requires the expertise of a licensed professional, such as a Registered Nurse or licensed therapist. | Non-medical care that assists with activities of daily living (ADLs), such as bathing, dressing, and feeding. |
| Medical Need | Must be medically necessary to treat an illness or injury. | Does not require a licensed medical professional and is provided to help with daily tasks. |
| Medicare Coverage | Covered under Medicare Part A and/or Part B, provided eligibility requirements are met, such as being homebound. | Not covered by Medicare if it is the only care needed. Exceptions apply if receiving skilled care simultaneously. |
| HCPCS Code Example | G0299 (skilled nursing services) | T1019 (personal care services) |
When is personal care covered by Medicare?
While Medicare does not cover T1019, it may cover home health aide services, which can include personal care, but only under very specific circumstances.
Requirements for Medicare home health aide coverage
To receive personal care from a home health aide under Medicare, you must first qualify for the home health benefit:
- You must be homebound, meaning it is a considerable and taxing effort for you to leave your home.
- You must need part-time or intermittent skilled nursing care or skilled therapy (physical, speech, or occupational).
- Your care must be ordered and supervised by a doctor.
- The care must be provided by a Medicare-certified home health agency.
If you meet these criteria, a home health aide can provide help with bathing, dressing, and other personal care activities, but only as part of your overall home health care plan. If you no longer need the skilled care, the home health aide services will also cease to be covered.
How to pay for T1019 and other personal care services
Since Medicare coverage for personal care is extremely limited, many people need to explore alternative ways to finance these services.
Medicaid
For individuals with limited income and resources, Medicaid is a primary source of funding for personal care. Medicaid coverage for personal care is provided through various state-specific programs, including Home and Community-Based Services (HCBS) waivers. Eligibility rules, covered services, and program availability vary by state. Some states explicitly use the T1019 code for Medicaid billing, and may even pay family members who are trained as personal care attendants.
Long-term care insurance
Private long-term care insurance policies are designed to cover services that Medicare typically does not, including personal care. These policies pay for services that help with ADLs over an extended period. The benefits and coverage will depend on the specifics of your policy, which is why it is essential to understand your plan's terms and conditions.
Medicare Advantage plans
Medicare Advantage (Part C) plans are required to provide at least the same level of coverage as Original Medicare. However, many plans offer supplemental benefits, which may include some coverage for personal care or homemaker services that are not covered by Original Medicare. Contact your specific Medicare Advantage plan provider to understand what additional benefits they offer.
Private pay and other options
For those without Medicaid or long-term care insurance, paying out-of-pocket for personal care is an option. You can hire a personal care attendant directly or use a home care agency. Other potential resources include Veterans' benefits for eligible individuals and community-based programs. An Advance Beneficiary Notice of Noncoverage (ABN) from your provider will formally inform you that Medicare is unlikely to cover a service, at which point you can choose to proceed and pay for it yourself or seek other funding.
Conclusion: Navigating personal care coverage
To summarize, the answer to Does Medicare pay for T1019? is generally no, because it is considered non-medical custodial care. While Medicare does not cover the personal care services billed under T1019 on their own, personal care from a home health aide can be covered if you also require and receive skilled, medically necessary care. Due to these strict limitations, beneficiaries must proactively seek alternative funding solutions for long-term personal care needs. Exploring state Medicaid programs, long-term care insurance, or potential supplemental benefits through a Medicare Advantage plan are the most common paths for covering these essential services. Working with a healthcare provider to develop a comprehensive plan of care is the best way to determine your eligibility for any available benefits and navigate your options.
