While B and MA both usually cover certain at home care, MA is likely to provide broader coverage and for less out of pocket cost. It should be noted that regular Medicare and MA may help provide home care that is medically necessary and not “custodial care”, as discussed below.
Medicare enrollees are eligible for in-home care under Medicare provided under the following conditions:
• The patient is under the care of an appropriate and Medicare approved doctor who reviews his or her treatment plan regularly.
• The doctor has certified and documented that the patient is homebound.
• A doctor has certified that the patient needs skilled nursing care or some type of therapy.
• The patient only needs physical, speech, or occupational therapy for a limited period of time.
• The need for skilled nursing is only part-time or intermittent.
• Any home health agency used to provide the prescribed care is approved by Medicare.
As can be seen above, Medicare will not cover long term (more than 100 days) at home care. Also, any approved at home care services are usually 100% paid for by Medicare as long as the service provider is approved by and participates in Medicare. Approved at home equipment and supplies (known as Durable Medical Equipment (DME)) will require the patient to pay for 20% of the cost.
Custodial care refers to supportive care for those who are incapable of managing daily living functions, like dressing, bathing, or preparing food. Medicare will sometimes pay for short-term custodial care (100 days or less) if it’s needed in conjunction with prescribed and authorized in-home medical care ordered by a doctor. At home care that is just custodial is not covered by Medicare. The types of in-home care that are covered by Medicare are listed below.
Medicare will pay for intermittent nursing services, meaning that care is provided either fewer than seven days a week, or daily for less than eight hours a day, for up to 21 days. Sometimes, Medicare will extend this time frame if a doctor can provide a precise estimate on when that care will end.
Skilled nursing services are generally required to treat an illness or assist in the recovery of an injury. Those who provide this care need to be duly licensed to administer medical treatment such as injections, catheter changes, wound dressings, and tube feedings.
The maximum amount of weekly hours Medicare will pay for is usually 28 hours, though in some circumstances, it will pay for up to 35. But it won’t cover 24-hour-a-day care.
Medicare covers physical therapy when it’s required to help patients regain movement or strength following an injury or illness. Similarly, it will pay for occupational therapy to restore functionality and speech pathology to help patients regain the ability to communicate. However, Medicare will only pay for these services if the patient’s condition is expected to improve in a reasonable, predictable amount of time, and if the patient truly needs a skilled therapist to administer a maintenance program to treat the injury or illness at hand.
Medicare will pay for medically prescribed mental health services that allow patients to cope with the emotional aftermath of an injury or illness. These may include in-home counseling from a licensed therapist or social worker. However, Medicare will only cover these services for patients receiving skilled nursing care.
This is the largest need overall for at home care. Medicare will cover part of the cost of medically necessary equipment as prescribed by a Medicare approved doctor for in-home use. This includes items such as canes or walkers, wheelchairs, blood sugar monitors, nebulizers, oxygen, and hospital beds. Patients typically pay 20 percent of the Medicare-approved amount for such equipment, as well as any remaining deductible under Part B. These amounts can be different, usually more liberal, under a MA plan.