Financial Advisor: Understanding Medicare Home Health
Home health care services in the United States come with a substantial price tag. As reported by Genworth's 2021 Cost of Care Survey, the average daily cost for a home health aide is $154 nationwide. Consequently, employing a home health aide for a full year, working 40 hours a week, would amount to a significant $56,160.
Medicare is a government health insurance for people aged 65 and above, and some younger individuals with disabilities. It provides coverage for specific home health care services.
Home health care is a cheaper and more convenient choice, with similar effectiveness to hospital or nursing facility care.
Knowing what Medicare covers and doesn't cover can save you time and money for you and your family.
Definition of Home Health
Home health care is skilled nursing care and therapy services provided at a patient's home. It is used to treat an illness or injury. This information is stated by Medicare. It is intended to offer part-time support and does not include constant custodial care.
The delivery of home health care is entrusted to licensed healthcare professionals, such as registered nurses, physical therapists, and occupational therapists.
Medicare provides coverage for home health care for a limited period. This coverage is typically available after a hospital stay or when a doctor determines that skilled care is required.
Eligibility for coverage requires the care to be intermittent, implying that it doesn't necessitate daily attention or continuous supervision. Furthermore, the services must be furnished by a Medicare-certified home health agency.
Home Health Covered by Medicare
While Medicare offers coverage for specific home health care services, it does not extend to all types of care. Here is a breakdown of what is covered:
Skilled nursing care: This category includes services like wound care, medication management, intravenous therapy, and education for you and your caregivers about prescription drugs or diabetes care. These services are provided by either a registered nurse or a licensed practical nurse.
Physical therapy: Medicare covers physical therapy services aimed at restoring mobility, improving strength, and promoting overall physical well-being. These services are provided by a licensed physical therapist.
Occupational therapy: These services focus on helping you regain skills necessary for daily activities, such as bathing, dressing, and eating.
Speech-language pathology: Speech therapy services are covered for beneficiaries who require assistance with communication or swallowing difficulties.
Medical social services: This can include counseling or assistance in finding resources in your community, provided by a licensed social worker. However, Medicare will only cover medical social services if you are receiving other skilled care simultaneously.
Medicare will cover these services if you receive care less than seven days a week or less than eight hours each day, over a period of 21 days or less, with some exceptions in special circumstances.
Additionally, if you have dementia and meet the criteria for services, you may be eligible to receive up to 35 hours a week of covered home health care services.
How do you Qualify?
To qualify for Medicare-covered home health care services, you must satisfy the following conditions:
Enrollment in Medicare Part A and/or Part B is necessary.
A certifying doctor must oversee your care and determine the need for home health services.
Your doctor must create a personalized plan of care, outlining the required covered services. This plan includes details about the specific professionals involved, service frequency, necessary medical equipment, and expected outcomes from the care.
Being "homebound" is a requirement, indicating that leaving the house involves substantial effort or poses health risks.
Your doctor and home health team must review and recertify the care plan every 60 days.
You must visit your doctor either 90 days before beginning home health services or within 30 days after starting them.
Home health care services are provided exclusively by Medicare-certified agencies. The personnel from the agency will coordinate and deliver the services prescribed by your doctor.
After your doctor refers you, a representative from a home health agency will get in touch with you. They will arrange a meeting and come to your home to assess your condition and discuss the necessary actions.
What is the cost?
According to Medicare's website, people on Original Medicare who meet certain requirements don't have to pay for home health care services.
Private insurance companies offer Medicare Advantage plans that provide the same home health care coverage as Original Medicare.
However, it's important to note that Medicare Advantage plans necessitate the selection of healthcare providers from within the plan's network. Additionally, various rules and costs may apply, making it crucial to contact your specific plan provider to obtain detailed information.
Before commencing any services, the home health agency should provide you with comprehensive information regarding what Medicare will cover. They need to be clear about things Medicare won't pay for and tell you how much you might have to pay. This information should be conveyed both verbally and in writing.
You might encounter a document called the Advance Beneficiary Notice of Noncoverage, or ABN, before the agency initiates services or supplies. The ABN serves as a notice explaining instances where Medicare is unlikely to cover certain services. For instance, if the home health agency deems a service medically unnecessary, it may not be covered.
Medicare does not cover round-the-clock custodial care. This type of care includes assistance with daily tasks such as bathing, getting dressed, and cooking meals. Moreover, housekeeping, meal delivery, and transportation are also not covered by Medicare.
You may have to pay for services or supplies that Medicare doesn't cover. Therefore, it's crucial to understand the associated costs beforehand. If you have any questions regarding your ABN, do not hesitate to discuss them with a staff member at the home health agency.
Here's an important tip: If you believe that a particular service or supply should be covered by Medicare, you have the right to request the home health agency to directly submit your claim to Medicare. Medicare will then review the claim and determine whether payment can be made.
Remember, it's your right to have the agency bill Medicare on your behalf, so don't hesitate to exercise that option if needed.
Will Medicare pay for family caregivers?
While Medicare's coverage for home health services is limited, Medicaid steps in to offer additional support through caregiver payment programs.
Every state, along with the District of Columbia, provides some form of program via Medicaid that enables clients to select a family caregiver. These caregivers are then compensated with Medicaid funds for providing care to their loved ones at home.
Medicaid serves as a health insurance program catering to individuals with lower incomes. In 2023, around 12.5 million people were eligible for both Medicare and Medicaid, known as being dual-enrolled.
Each state operates its own Medicaid program, leading to variations in eligibility criteria and payment structures for family caregivers. Typically, eligibility is determined based on the beneficiary's functional and financial needs.
For state-specific eligibility criteria, you can refer to the information provided here. If you are already enrolled in Medicaid, it is advisable to reach out to your state's Medicaid office for further details.
Bottom Line
Medicare provides coverage for specific home health care services. Home health care is often a more affordable and convenient choice compared to receiving care in a hospital or nursing facility. However, it is equally effective. Familiarizing yourself with Medicare's coverage and exclusions can help save significant time and money for you and your loved ones.
Sources:
https://www.thepennyhoarder.com/retirement/medicare-home-health-care/
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