Most citizens in the U.S. rely on Medicare, which is the country’s leading health insurance program. By the end of 2019, more than 61 million seniors were enrolled in Medicare health programs. And since then, the number has continued to rise exponentially.

With millions of people benefitting from these programs and thousands of agencies delivering health care services under Medicare, making the right choice can be overwhelming. This guide provides deeper insights into Medicare-covered home care services. Keep Reading!

Qualification Requirements

If you’re aged 65 years or older and are receiving any form of Social Security benefits, then you’ll be automatically enrolled in Medicare. You’ll get enrollment cards three months before your 65th birthday. But if you aren’t automatically enrolled, you can still sign up at a local Social Security office.

Medicare patients can get help from any doctor, nursing home, hospital, pharmacy, or home care provider approved by Medicare. Before a visit, it’s important to verify that the doctor or health care provider accepts Medicare.

To receive in-home care, you should also have both Hospital Insurance (coverage through Medicare Part A) and Medical Insurance (Medicare Part B). Plus, you should meet the following criteria:

Be Under the Care of a Medical Doctor

The doctor should prescribe a care plan that incorporates all the medical services necessary for treating and maintaining the patient’s health condition. Generally, this care type of care is offered on a short-term basis, so the doctor will be required to re-certify the plan after every 60 days.

Work With a Certified In-Home Care Provider

Leaving your home requires a considerable amount of effort. Plus, it can be very costly. Your loved one will probably need mobility aid, special transportation, and another person’s assistance to move. Even if they’re able to attend medical appointments, religious services, and adult day care on their own, they can still qualify for Medicare services. The home care company you choose should have a doctor’s certification for various services, including:

Skilled Nursing Care: Intermittent care typically includes involves the provision of part-time services that need less than 8 hours per day over a maximum period of three weeks. Of course, there are exceptions in certain circumstances, but Medicare won’t generally cover additional care.

Professional Therapy Services: This type of care includes services, such as physical therapy, occupational therapy, and speech-language pathology. It’s important to note that these services should only be administered by a qualified therapist.

Skilled therapy will go a long way in improving your loved one’s condition and helping them lead a healthier life. To create a successful maintenance program for the condition, be sure to choose a reputable service provider. Home health care services should only be provided by a Medicare-certified facility.

Types of Services Covered By Medicare

Medicare’s primary objective is to provide elderly people with short-term skilled services at their own homes. It’s an incredible alternative to recuperating in a hospital or a nursing home. Skilled nursing services refer to those types of services that must be provided by medical professionals, like Licensed Practical Nurses (LPNs) or Registered Nurses (RNs). Some of these services include injections, monitoring of a patient’s symptoms. Catheter changes wound care, and patients or caregiver education.

In short, skilled therapy services should always provide under the supervision of a certified physical therapist, speech-language therapist, or an occupational therapist. Occupational therapy typically helps your loved one to independently engage in daily living activities and adapt these tasks to the surrounding environment so as to improve their functionality as well as accessibility.

Physical therapy, on the other hand, focuses on improving and restoring the patient’s strength. In addition, it also aims to restore balance and motion for optimal physical function. Speech-language therapy improves the patient’s ability to speak and communicate. Plus, it also helps them overcome swallowing difficulties or dysphagia.

Remember, the above services will only be covered by Medicare if they’re deemed effective ways of maintaining the patient’s condition. Medicare standards will carefully determine the eligible frequency as well as the duration of treatments. According to Medicare, home health care services are designed to prevent placement in a nursing home or an assisted living community.

Does the Program Cover Unskilled In-home Care Services?

It’s important to note that Medicare won’t pay for unskilled home care. So, if those are the only services you need, then Medicare might not be the best option for you. Personal care or homemaker services will only be offered if they’re part of the skilled services outlined in the care plan. Besides, Medicare doesn’t usually cover around-the-clock home care or any meals delivered to the home.

How Much Do Home Care Services Cost?

With Medicare coverage (Part A and Part B), qualified seniors will pay nothing for in-home health care services that are recommended by a doctor and administered by a certified home health care company. Any additional services offered outside of the approved care plan won’t be covered and should be paid out of pocket.

Before the services are delivered, your home health company should provide a care plan that indicates what’s eligible for Medicare coverage. It should also highlight what isn’t eligible for coverage. A written notice referred to as an “Advance Beneficiary Notice of Non-coverage” or ABN will highlight any services as well as medical equipment that Medicare won’t cater for. In addition, it will also detail the costs that the patient will bear responsibility for.

When Is Medicare Coverage Applicable?

It’s important to note that Medicare is designed to provide coverage when someone becomes sick or gets injured. And this includes X-rays, hospitalization, hospice, lab tests, as well as doctors’ services.

Nowadays, however, Medicare has expanded its coverage to also cater to an extensive range of preventive as well as screening services.  Examples of these services are cardiovascular screening, cancer screening, glaucoma tests, diabetes screening/supplies, and smoking cessation counseling.

For those who meet certain criteria for in-home care, Medicare also caters to part-time nursing care, physical and occupational therapy, part-time health aides, as well as medical supplies and equipment. With access to such services, you can always rest assured that your loved one is receiving the highest level of care. You want them to be happy, right? Then Medicare is the best way to go!

What Isn’t Covered By the Medicare Program?

Medicare is typically designed to provide long-term nursing care. So, families can’t possibly rely on Medicare to provide around-the-clock at-home care, delivery services, or meals.

Although Medicare recently incorporated numerous preventive services to its coverage, many other health care needs aren’t covered yet. These include dental care, routine physical exams, medical treatment outside America, and the provision of glasses, as well as, hearing aids. Moreover, Medicare doesn’t cover elective procedures, such as cosmetic surgery, acupuncture, and massage therapy.

Make sure that the doctors you choose to accept Medicare. Otherwise, the program might not even pay for covered costs. This also applies to outpatient care, prescription drugs, and home care services.

Understanding the Different Parts of Medicare

Different parts of Medicare have different payment systems. And the patient’s out-of-pocket expenses will depend on how they receive the benefits of each part of the program.

Medicare Part A

Part A benefits will pay a significant amount of your hospital bills in the United States. It includes drugs, medical supplies/equipment, special care units, lab/diagnosis tests, nursing services, rehabilitation, operating room charges, and special treatments.

Part A coverage isn’t hinged on the necessity of medical service. Thus, it’s compulsory in all inpatient settings. Since this type of coverage has a deductible associated with it, you might be responsible for paying a portion of inpatient treatment bills. As of now, everyone with Part A coverage pays a deductible of 1,408 dollars for each period of hospitalization as well as copayments for each day beyond the first 60 days of your hospital stay.

Most people purchase private Medicare plans to cater for the extra costs left over after Medicare makes its payments. But as long as you worked and paid Social Security plus Medicare taxes for 10 years or more, you won’t need to pay any premiums.

Medicare Part B

Medicare Part B is optional coverage. So, it has to be purchased. Every citizen who’s over 65 years of age is eligible. In this plan, doctor bills are the biggest chunk of expenses that are covered. Whether the doctor’s services are offered in a hospital or clinic, the plan will cater for all related expenses. Part B also covers other tasks performed by the medical staff and any other drugs administered in the office.

Additional services covered by Medicare Part B include X-rays, limited chiropractic care, ambulance services, therapy (physical, speech, and occupational),  mental health services, tobacco use cessation, preventive screenings, cardiac rehabilitation, kidney dialysis, vaccines, lab work, etc. For these services to be covered, however, they must be ordered by a qualified physician. Plus, they should be deemed medically necessary. Even more, they should be offered by a doctor or home care provider that accepts Medicare.

Part B typically costs $144.60 in monthly premiums. This amount is automatically deducted from your Social Security checks. It’s also important to note that the program comes with an annual deductible of $198. And after the deductible, Medicare pays a whopping 80% of the approved amount for covered medical services and 80 to 100% of the approved amount for covered outpatient services as well as medical equipment.

Part C

Part C of the Medicare plan is a private insurance policy that replaces Part A and Part B. Once you get enrolled in a private Medical Part C program, you’ll no longer get coverage through Medicare Part A or Part B.

Part C plans typically eliminate some co-payments as well as deductibles. Plus, they might provide additional perks, making them attractive to some seniors. If you didn’t enroll in Part C or D of the Medicare program when you turned 65, you can still do so during Medicare’s annual enrollment program.  

Part D

Part D refers to a collection of various private plans that cover prescription drugs. The federal government often sets the rules for the programs, but they’re issued by private insurance firms. Every plan under Part D covers different premiums, medications, as well as copayments. When choosing a plan, avoid focusing solely on the cheapest monthly premium. Instead, you should seriously consider if it covers the specific drugs required and the applicable types of copayments.

Remember, every state offers different plans. So, be careful not to make the wrong decision when shopping around for this type of medical insurance. Otherwise, you might not be able to access the services you truly need.

Key Takeaway

If you wait until 3 months after your 65th birthday to enroll in Medicare Part B, then you might not be able to enroll until the first day of the following year. Plus, the coverage you enroll for won’t start until July 1 of that particular year.

Medicare’s website contains information about Part B coverage, enrollment, as well as eligibility criteria. Part B’s daily operations, however, are commonly handled by private insurance companies referred to as Medicare Part B “carriers”.

It’s also important to note that there’s a big difference between medically necessary in-home care services and personal care offered by an inexperienced caregiver. Understanding the distinction between these two levels of care is important for determining who’s qualified for Medicare-covered home care services.

Remember, Medicare only covers home care services prescribed by a medical professional and provided by skilled caregivers. But patients should meet specific eligibility criteria.

The Bottom-Line

Are you ready to leave your home? Do you want to move into a nursing home or a senior care facility? The answer is no, right? Nobody on earth wants to be detached from their lovely home.

With home care services, care is brought right to your home. The elderly, disabled, or those who’re ill can now be cared for in the comfort of their own homes. The above guide will help you and your loved ones understand everything about Home Health Care Services Covered by Medicare and how various aspects of the program work. It will also help you determine if Medicare will cover senior care services such as assisted living community and home health care.