Do Medicare or Insurance Cover Home Health Care?

When recovering from an illness or even the normal aging process interferes with your loved one’s ability to live comfortably at home, you have more options than you might think. Home health care in New York can provide the help and supervision necessary to keep your family together. And while payment is often a concern, we have all the information you need to understand how insurance coverage may offset the costs incurred by these services.

Does Medicare or Other Insurance Cover Home Health Care?

This question is going to take some time to answer, so let’s break it into two parts. We’ll start with Medicare, which does cover home health care services. Those services must be prescribed by a doctor and provided by an agency certified by Medicare. When both qualifications are met, Medicare can pay 100% of the costs for up to 60 days at a time.

This period is renewable, which simply means Medicare may continue coverage if your doctor re-orders the home services as medically necessary every 60 days. You must also meet some conditions as follow:

  • You must be unable to leave your home without the help of another person or devices like a walker or wheelchair
  • You are certified by a doctor as needing skilled nursing and/or a form of therapy
  • The above certification arose from a documented, in-person visit with the doctor not more than 90 days before the start of home care
  • You have a treatment plan that your doctor established and regularly reviews

What’s Covered?

Either Medicare Part A or B will cover a variety of home health solutions. These include part-time or intermittent skilled nursing care and home health aide services. The latter refers to personal, hands-on care like help with bathing, dressing, and grooming. Additional services likely to be covered include:

  • Physical therapy
  • Speech-language pathology services
  • Occupational therapy
  • Medical social services
  • Injectible osteoporosis drugs for women

The frequency and time period recommended for your services must be reasonable. In addition, your needs must be complex enough that only qualified therapists can safely and effectively provide the services necessary. You must also meet one of the following requirements:

  • Your doctor believes your condition can improve in a reasonably predictable amount of time
  • A skilled therapist is necessary to develop a maintenance program for your condition
  • A skilled therapist is necessary to safely and effectively provide therapy to improve your condition

What’s Not Covered?

Not all services are covered by Medicare, and making this distinction will help you plan accordingly. For instance, 24-hour-a-day care at home is not eligible for Medicare payment. Nor are meals delivered to your home. Homemaker services like cleaning and shopping are not covered when those are the only services you need. The same is true of personal care services like dressing or bathing; when this is the only care you need, it’s not covered.

To meet the homebound requirement, a doctor must certify you’re not able to leave. However, you’re still eligible for home health services if you need to leave home for medical treatment, to attend religious services, or to go to adult daycare.  

An Example of Medicare Paying for Services

Here is a scenario in which Medicare would cover home care services. Mrs. Matthes broke her tibia and underwent surgery. She is now home and needs help getting around the house, dressing, and bathing. She also needs physical therapy (PT) and occupational therapy (OT). Mrs. Matthes qualifies for in-home care as long as PT remains necessary and she is homebound.

What About Medicaid?

This federal-state health insurance program provides coverage for children, the blind, elderly, disabled, and other people who receive federal assistance. Eligibility is determined by income.

Medicaid’s coverage is more complex than Medicare because each state independently governs different pools of money for different services. In New York, the New York State Department of Health (DOH) determine which in-home services are eligible for Medicaid payment.

Traditional Health Insurance Plans

Although coverage varies widely from plan to plan, private health insurance policies may pay for select home care services. We know that reading through a lengthy policy isn’t practical, and the verbiage used is often confusing. For this reason, we recommend you contact your insurance provider directly and ask about the coverage provided for home care.

Ensure all of your questions are answered before terminating the call. And then calculate what your out-of-pocket expense will be so you can establish a new budget.

Long-Term Care Insurance Benefits

You can purchase long-term care insurance from private companies to pay for the costs of assisted living, nursing home care, and home health services. Different plans offer different benefits, so it’s crucial that you understand the services covered at the time of purchase. Assistance with personal home care may be provided only if the plan allows for non-medical services; clarify this with the representative so you know what you’re getting.

The best time to purchase long-term care insurance is now, before you’re beset by chronic illness or serious medical conditions. Older seniors and those with health complications are unlikely to qualify for coverage, according to data from the American Association for Long-Term Care Insurance.

Life Insurance Options for New York Residents

Seniors with life insurance policies may be able to use them to pay for home care. Options include surrendering the policy for cash or taking a loan against the policy’s value. Some policies also feature an “accelerated death benefit” rider, in which a cash advance gets subtracted from the total death benefit amount. This comes with several specific requirements, including that the policyholder, continue to pay the policy’s premiums.

Work with Your Home Care Provider

Arranging for in-home services can be both complicated and costly. It is for these reasons that you must work closely with the agency you choose to provide these services. Ask for help in qualifying for Medicaid and/or Medicare as well as advice on supplemental insurance plans. Your agency should also be able to craft a long-term financial strategy that protects family assets and eases the financial burden of keeping a loved one at home.

Answers to Common Questions

Many people ask about the advantages of using an in-home care agency. We’re always quick to say home health care helps with faster recoveries, reduces future hospital admissions, and allows patients to be discharged sooner from the hospital. It also keeps those recovering from an injury or illness at home, where they feel safer and happier and can receive much-needed attention from family and friends.

Likewise, people of all ages use in-home care, including those who have short-term health needs or need training on how to care for themselves following a new health diagnosis. Home care is also beneficial for new parents caring for preemies.

When Does Service Begin?

As stated earlier, Medicare (and most other insurance plans) require that a doctor writes a prescription for home care services. Once that prescription is written, the doctor completes a coordinated treatment plan and regularly reviews the patient’s progress. If a person wants services without a prescription, a home care consultant can recommend a care plan based on individual needs and budgets.

Paying for in-home care may seem complicated, but it doesn’t have to be. We can provide guidance in a variety of ways, from information on pooled trusts to developing personalized care plans. And we’ll ensure the recommendations you receive are tailored to your needs. Call Parent Care today and keep your loved one safely at home. 

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