Does Medicare Cover Home Health Care for Elderly People?

The short answer is Yes.

But, I have to clarify an area of confusion up front. Many people confuse Home Health Care with In Home Care services for seniors. They are 2 different animals. Home health care services are medical services provided by licensed professionals. In home care services are basic caregiving services that include things like companion, bathing, and light house work services.

Medicare will cover home health care for eligible elderly people. This is a federal (meaning government) health insurance program that was set up in the 60s, to provides insurance coverage for a range of medical services, including home health care services.

For background, the Medicare program was established in 1965 by President Lyndon Johnson, as part of the Social Security Act. It was created to ensure health insurance coverage for any American that was 65 or older. But it also covers younger people with certain disabilities and also those that have end-stage renal disease.

It was originally divided into Medicare parts A and B. Medicare A benefits cover hospital and skilled nursing home stays, home health care services, as well as paying for home medical equipment. Medicare B benefits cover services on an outpatient basis where services are provided out side of the home.

Does Medicare Advantage Cover Home Health Care

A law passed in 1997 allow Medicare benefits to be managed by 3rd party insurance companies like Blue Cross and Aetna (to name just 2) to manage a person’s Medicare benefits. These “managed” plans are divided into 2 categories. They are Medicare Advantage plans and Medicare HMO plans. They both will cover home health care services, but some Medicare Advantage plans may actually provide even more benefits beyond what is covered by Medicare part A. On the other hand, Medicare HMO plans may have a co-pay with services and require you to use specific companies within a specific network

Who Qualifies for Home Health Care Services Under Medicare?

To be eligible for Medicare-reimbursed, an elderly person has to have worked and paid into the Social Security system, then they will be able to receive Medicare benefits once they reach 65 years old. In some cases, even if you haven’t worked and paid into the system, but your spouse did, then you may also be able to get Medicare to pay for home health care services. Also, immigrants who are lawful residents or citizens, have lived in the US for at least 5 years, and are 65 or older are also eligible to receive Medicare Benefits.

How to Qualify for Home Health Care Under Medicare

If you have Medicare and want to get home health care, you have to meet certain requirements. The first thing that’s needed is a physician’s order or referral for services be sent to an approved home health agency. Second, the person that is going to receive the services needs to be home bound. What this means is that the condition that a person has makes it difficult or unsafe to leave the home, need to use an assistive device like crutches or wheelchair, or, the assistance of another person to leave the home.

For instance, if a person has difficulty walking or breathing to the point that they need an assistive device, portable oxygen, and the assistance of another person then they would be considered “homebound”. Naturally, a person who is bedbound would be considered homebound.

Another requirement is that the services prescribed are skilled services. In general, any service that requires a licensed professional to perform, is considered “skilled”. If an elderly person has had a stroke and has difficulty swallowing, then they would need the “skilled services” of a Speech Therapist. If a person had broken their leg and had to use crutches to get to their 2nd floor bedroom, they would need the skilled services of a Physical Therapist. On the other hand, if they only need someone to bathe them once or twice a week, then this wouldn’t required a “skilled” or licensed professional to perform the bathing. Although the services of a home health aide to assist with bathing, it’s not considered “skilled” and therefore is not a stand alone service that Medicare would cover.

To get Medicare to cover home health services, the referred services would also have to be considered, medically necessary. For instance, a person who has just had a hip replacement, or had been in the hospital 2 months with COVID, the services of a skilled physical therapist to teach “gait training” may be “medically necessary”. However, it would not be considered medically necessary for a person who had a previous stroke, went through the rehab process at the time, and has not walked in 10 years, to receive home health physical therapy for gait training as it is unlikely the patient would learn to walk after such a long time.

What Home Health Care Services Are Covered by Medicare?

In general, home health care services include 3-4 health care “disciplines” which provide the skilled services. Skilled disciplines are considered “stand alone” meaning that they can be the only services received. Home health also includes 2-3 “services” that are “unskilled”. This means that to receive them, a skilled service has to be ongoing. For instance, if you’re wondering how to get home health aide services for the elderly, they will have to be receiving either Nursing, Physical, Occupational, and/or Speech therapy services also.

The common healthcare disciplines include the following “stand alone” disciplines:

Skilled Services

Skilled Nursing Care: This includes a range of medical services provided by a registered nurse or a licensed practical/vocational nurse, like caring for wounds, help and education in managing medications, performing blood draws or urine samples, administering IV medications, and monitoring of vital signs.

Physical Therapy: They teach and administer exercises and treatments that help the patient their regain strength, ability to move around after having an injury, surgery, or illness. Physical therapists will also provide care giver training when it comes to assisted mobility as well as recommend and instruct in proper use of medical equipment that helps a person move better.

Occupational Therapy: They teach exercises and provide education in order to help improve a person’s ability to do their ADLs like bathing, dressing, meal prep, and activities that require writing.

Speech Therapy: These professionals do a lot. Their services include helping people think, speak, and swallow better.

Unskilled Services:

Medical Social Services: These professionals can provide counseling to help patients and their families cope better with the emotional, social, and financial issues that they are dealing with because of their medical condition. They can also provide education and assistance applying for community resource programs and navigating the medical system as a whole

Dietician Services: Dieticians provide education and counsel individuals and their families on nutrition issues and healthy eating habits that are required by their medical condition.

Home Health Aide Services: These folks provide personal care services such as assistance with bathing, dressing, and grooming.

How to Set Up Home Health Care For Elderly Folks

As was mentioned above, you need to get a prescription from your family doctor. The prescription should include the person’s diagnosis, as well as what services the doctor feels are needed to address the stated diagnosis. For instance, if the individual has had several incidents of falls, the doctor may prescribe home physical therapy to teach a strengthening or balance program or evaluate the patient’s home for safety and recommend any medical equipment that would help prevent falls in the future.

Another scenario may be that an individual may have trouble managing their diabetes or their blood pressure medication and the doctor prescribes home nursing services to help the individual understand how to better control or manage these chronic conditions.

In either of the above examples, the doctor (or the home care team) may recommend the services of the home health aide to help with hygiene, or medical social work to come in on the case to assess a person’s need for community service relief, like meals on wheels, or other community organization that provides services to the elderly. Here is more information about the process

How Long Will Medicare Pay for Home Health Care Services?

Just how long Medicare will pay for home health care services is really dependent on the individual needs of the person receiving services. Medicare’s pay periods are broken down into 30 and 60 day periods. And, most home health agencies have to meet certain criteria to continue to treat past that time. But, services are able to be extended if there continues to be a medical necessity and the services of skilled clinicians is needed.

In some cases, with HMO patients, certain services may continue for a year or more because of contractual agreements between the insurance company and the home health agency. However, in these cases, there must be a medical need and the services may be limited. A common scenario may be that an individual has a urinary catheter that needs routine monitoring and changing by a home health nurse. Services like this can continue but it is unlikely that additional services will be extended.

To summarize, Medicare will cover the cost of certain home health care services, but, there will probably be limitations on that coverage, like the number of visits or how long services can last. So, it’s important for patients and their families to work with their healthcare provider and the home health care team and develop a plan of care that’s tailored to the specific needs.