Yes.
No.
In some situations.
As you probably know there is no short or easy answer to this question. While many insurance providers will pay for certain home care services, the specifics vary from plan to plan. What you may not know is that many insurance companies follow Medicare guidelines when it comes to coverage for home care. For that reason, we have found that understanding Medicare coverage is a great help in understanding insurance coverage in general.
So let’s talk Medicare. And while we’re at it, let’s look at Medicaid too, because the two are often confused.
The Different “Parts” of Medicare
Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Medicare is age or diagnosis based, not income-based. There are four different “parts” to Medicare benefits—A, B, C, and D. Let’s have a look at each:
| PART | COMMONLY KNOWN AS | WHAT IT COVERS |
|---|---|---|
| A | Hospital Insurance. With Part B referred to as “Original Medicare.” | Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. |
| B | Medical Insurance. With Part A, referred to as “Original Medicare.” | Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services. |
| C | Medicare Advantage Plans or MA Plans | A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage. |
| D | Prescription Drug Coverage | Part D adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans. |
WHEN CAN I USE MEDICARE BENEFITS FOR HOME CARE?
Medicare Part A covers home care WHEN:
- A client is homebound AND
- Has a skilled need. A skilled need is considered something that requires a nurse or a physical therapist.
Occupational Therapy (OT), Speech Therapy (ST) and Home Health Aide (HHA) cannot be provided as stand-alone, in-home services; they can be provided only in conjunction with other care that meets the above criteria. If the client qualifies with these two criteria (homebound and has a skilled need), THEN OT, ST, and HHA services can be covered only for that episode of care. As soon as the skilled need is no longer present, all care must cease.
For example: Mr. Smythe broke his hip and underwent hip surgery. He is finally home but needs dressing changes, physical therapy (PT) and occupational therapy (OT). Mr. Smythe qualifies for in-home care as long as he needs the nurse or PT and is homebound. Once he can go to outpatient therapy, Medicare will no longer cover any services. Silver Lining Home Healthcare is uniquely positioned to not only care for Mr. Smyth in his home, but also to assist him in the transition from Medicare-covered services to sustained quality of life by picking up where Medicare drops off.
Medicare Part B views therapy differently than Medicare Part A.
- Part B can provide PT and/or OT in the home even when a client is NOT homebound, and has more flexibility when it comes to maintenance therapy.
This is an important distinction. Even if you or your loved one do not meet the 2 criteria above, Medicare Part B may be able to help.
For example: Joan has been diagnosed with Parkinson’s disease. Although she is still able to be out and about, she is experiencing a worsening of her symptoms and her family is concerned for her safety in the home. Under Part B, a PT company can assist Joan with a home evaluation, home modification recommendations, and provide services. Silver Lining Home Healthcare partners with Aging in Place Specialists (AIPS) who does just that; they offer in-home outpatient physical therapy, as well as home accessibility consulting and modification services. AIPS bills Medicare Part B. When you or a loved one is facing a situation like Joan’s, ask a potential provider if they bill Medicare Part B.
To summarize: For Medicare to cover in-home services under Medicare Part A, the client must have a skilled need AND be homebound. When they meet those qualifications, they can then also receive OT, ST and HHA during that episode of care. For Medicare to cover in-home services under Medicare Part B, the client must have a “medically-necessary” need as defined by the therapist or physician.
MEDICAID
Medicaid is a jointly funded, federal-state health insurance program for low-income and needy people. It covers children, the aged, blind, and/or disabled and other people who are eligible to receive federally assisted income maintenance payments. Medicaid is income-based health insurance and uses the Federal Poverty Level Table (FPL) to set income criteria.
WHAT DOES MEDICAID COVER?
Medicaid is more complicated because each state is run differently with different pools of money for different types of in-home care. For Delaware, we have Medicaid (regular) which is run exactly like the Medicare Part A provided the income eligibility requirement is met. Medicaid will cover a certain level of home care services, usually in short term situations.
For long term care, Delaware also has a Medicaid managed care model (formerly a waiver model) which allows persons with limited funds to apply for covered services in home care, assisted living or skilled nursing facilities. Because the financial requirements for Medicaid and Medicaid managed care are different, a person can often receive Medicaid managed care services before they become eligible for Medicaid itself. Medicaid managed care will then cover much more extensive long term care services, and the persons who administer these services are home care providers like Silver Lining Home Healthcare.
SUMMARY
If you’re looking to understand how insurance plans determine eligibility for in-home care, the Medicare guidelines are a great place to start. Most insurance plans design their policies based on the Medicare model. Use your insurance to its fullest capability, then supplement with a private duty agency for a well-rounded program of care. Home care, assisted living and skilled nursing facilities are all options as we age. The biggest factors in choosing care are: (1) goals of care (i.e. do you want 1:1 care, do you want to stay at home?) and (2) financial ability.
If you’re confused at all or want to chat, head over to our website and book a phone consult! silverlininghealthcare.com
ADDITIONAL READING:
· Medicare: https://www.medicare.gov/
· Medicaid/Medicaid Managed Care (Delaware): http://dhss.delaware.gov/dhss/dmma/
· For a look at cost of care in your area, visit this site:
https://www.genworth.com/about-us/industry-expertise/cost-of-care.html
