Medicare Home Health Care – What Medicare Doesn’t Pay For

Home health care refers to a broad array of medical services and equipment provided in the comfort and privacy of a senior’s own home for illness or injury care, often as an affordable and more convenient alternative to hospitalization or skilled nursing facility residency. Medicare Parts A & B as well as some Medicare Advantage plans provide some coverage for at-home health care services.

To qualify for Medicare-covered home health care, certain criteria must be fulfilled. Your physician must document that you’re homebound – meaning leaving without assistance is difficult or impossible – then meet the length and time requirements outlined by your plan of care. Finally, Medicare must approve of your home healthcare agency, showing they meet quality and safety standards.

Medicare-approved home healthcare plans typically cover nursing care, rehabilitative therapy, medical supplies and durable medical equipment; however, Medicare does not pay for custodial or long-term homecare aide services such as custodial care or long-term homecare aide services; programs like adult day care and chore assistance may be available through state Medicaid programs in these cases.

If you qualify, Medicare-approved home health care may be free if you choose a Medicare-participating agency that accepts assignment. This means they agree to accept Medicare’s approved amount as full payment for its services; nonparticipating agencies often charge more and require coinsurance or deductible payments from you.

Your doctor will usually determine that home health care is necessary due to recent hospital stay or medical condition, and provide a plan of care detailing duration and frequency requirements. Once met, Medicare will submit the claim directly.

Home health care costs vary based on individual circumstances; however, most should not be too costly. When considering this option for yourself or a loved one, always check with their insurer to learn what fees may apply if their assignment agency doesn’t accept assignments and how to appeal if necessary.

Home health agencies sometimes believe Medicare won’t cover all the services you need and may discontinue or reduce care services accordingly. When this occurs, home health agencies must issue an Advance Beneficiary Notice of Noncoverage (ABN), outlining why Medicare shouldn’t cover costs as well as providing instructions for filing an appeal if needed.