If you are thinking about recovering from an accident or illness at home, it is important to understand what services Medicare will, and will not pay for. You may also want to consider purchasing a home care insurance policy to fill in the gaps.

What Medicare Will Pay For

Figuring out what may, and may not be covered by Medicare is complicated. To get started, consider these fast facts from Medicare.Gov, the federal Medicare website:

  • Medicare will only pay for custodial services such as help bathing, using the toilet, taking medications and other daily activities, if you are also concurrently receiving skilled nursing or rehabilitative care.
  • Part-time skilled nursing provided for fewer than seven days a week, or daily for less than eight hours a day. Coverage is limited to up to 21 days, or possibly longer, when a doctor provides a precise estimate as to when care will end.
    • Medically necessary equipment prescribed by a doctor for in-home use.
    • Physical therapy that helps a patient regain movement or strength following an injury or illness.
    • Speech therapy that helps a patient regain the ability to communicate.
    • Medical social services.
    • Part-time home health aide services.
Medicare Coverage

What Medicare Will Not Pay For

Medicare will not pay for an aide if you only require custodial care (versus skilled care). In addition, Medicare will not pay for:

  • 24-hour-a-day care at home
  • Meals delivered to your home
  • Homemaker services (like shopping, cleaning, and laundry)
  • Custodial or personal care (including bathing, dressing, or using
    the bathroom and other daily activities).
No Medicare Coverage

Medicare Supplement insurance

A home care insurance plan can supplement Medicare coverage by paying for a portion of the costs of covered services not paid for by Medicare Part A or Part B. The most common uncovered costs include out-of-pocket expenses, Medicare deductibles, coinsurance, and co-payments.

Like Medicare, home care insurance does not pay for personal care assistance. But it does provide coverage for physical, speech and respiratory therapies and for other medically necessary treatment prescribed by a physician and provided by a skilled medical professional

Eligibility

If you are covered by Medicare Part A or Part B (or both), you will likely be covered by a home care insurance policy if:

  • You are under the care of a doctor and you are receiving services planned by a doctor and regularly reviewed by a doctor.
  • A doctor has certified that you are home bound.
  • You need, and a doctor certifies, that you need, one or more of these services:
    • Intermittent skilled nursing care.
    • Physical therapy, speech-language pathology, or continued occupational therapy services and the amount and time that services will be required is reasonable. To be eligible for skilled nursing or therapy services:
      1. Your condition must be expected to improve in a reasonable period of time, or
      2. You need a skilled therapist to create a program, or
      3. You need a skilled therapist to provide maintenance therapy for your condition, and,
      4. The home health agency caring for you is certified by Medicare.

It is important for you to know that you will not be eligible for home healthcare benefits if you need more than part-time or “intermittent” skilled nursing care. You may leave home for medical treatment or short, infrequent absences for non-medical reasons, and you can get home health care if you attend an adult day care program.

It is also important to know that, during the COVID-19 pandemic, nurse practitioners, clinical nurse specialists, and physician assistants can provide home health services without certification by a physician.

Good To Know

Before you commit to home health care, the home health agency should tell you (in writing) how much Medicare will pay for the services they will provide. The agency should also tell you (again, in writing) if any of their services or products will not be covered by Medicare, and how much each will cost. In addition, the agency should give you an Advance Beneficiary Notice (ABN) before providing any services or supplies that Medicare will not cover.

In addition to getting this information from your home health agency, you should also ask your doctor or health care provider how much the services and products that they will provide cost. Ask them if they accept your Medicare assignment and other insurance . . . and how much you will be responsible for out of pocket.

Get Help

Coordinating Medicare and home care insurance is complicated. Contact us (by clicking the GET AHCCCS MEDICAID HELP link at the bottom of this page) if ACCESSMed can help.

And, click this link to learn about Long-Term Care options from the official U.S. government Medicare website, Medicare.gov.

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