Are Non-Medical Home Care Services Covered By Medicare?

· 13 min read

Now, more than ever before, older adults are opting to age in place. Today, almost 90% of seniors want to remain in their current homes where they can maintain their independence, keep their community connections, and improve their quality of life. As a result, home care is becoming a leading care preference for seniors, and thankfully, technology is making this option viable for many. However, one of the biggest sources of confusion for many seniors and their family members is: Who’s going to pay for it? While Medicare is an option for some home care services, it may not be an option for all. Therefore, let’s dive into the topic of if non-medical home care services are covered by Medicare. 

What is Medicare?

Before exploring if Medicare covers non-medical home care, we must first clarify what Medicare is. To start, Medicare is a government-backed insurance program that generally covers all Americans over 65. Medicare coverage may also cover some individuals with chronic health conditions and disabilities. Today, there are four different parts to Medicare, which we’ll cover below. 

Understanding The Different Parts of Medicare

The different parts of Medicare, known as Part A, B, C, and D, are there to help cover specific types of services. Part A and Part B are known as Original Medicare because the federal government determines the premiums, deductibles, and coinsurance amounts you have to pay. Part C of Medicare is known as Medicare Advantage and is offered by Medicare-approved private companies that can determine their own out-of-pocket costs and rules for coverage. Medicare Part D is also run by private companies, but they must follow the rules set by Medicare. 

What Each Part of Medicare Covers: 

  • Part A of Medicare is hospital insurance, which is premium-free and covers in-patient hospital care, hospice care, and some skilled home health care services. 
  • Part B is considered medical insurance and covers outpatient care, medical equipment, some preventative services, and home health care. Unlike Part A, Part B requires that everyone pay a monthly premium based on their income. 
  • Medicare Part C, also known as Medicare Advantage, is a bundled plan that includes Part A, Part B, and Part D. These plans typically offer additional benefits that aren’t covered under Original Medicare. 
  • Part D of Medicare provides prescription drug coverage and helps protect you against higher drug costs in the future. 

So Does Medicare Pay for Home Care Services? 

At first glance, it appears that home care services are covered by Original Medicare. However, it’s not as cut and dry as that. For starters, not all home care services are the same, and clarifying this distinction is important to determining if and how Medicare will cover these types of services. So let’s explain how they differ and how that impacts coverage. 

Skilled Home Health Care vs. Non-Medical Home Care

Skilled home health care is a service that’s prescribed by a physician and then administered by a nurse, doctor, home health aide, or certified nurse assistant. Individuals receiving this form of care likely receive assistance with wound care, injections, medication administration, and other tasks requiring medically trained professionals. 

Non-medical home care, on the other hand, is provided by high-quality caregivers and is a great option for those who want to maintain their daily routine at home but require some assistance. Caregivers may assist with non-medical tasks, such as bathing and ambulation, light housekeeping, meal prep, companionship, etc. 24 Hour Home Care is a non-medical in-home care provider.

The Original Medicare: Best for Skilled Home Health Care Services

Now that we’ve clarified the difference between skilled medical home health care and non-medical home care, we can explain how coverage works. The Original Medicare plan, which is Part A and Part B, covers skilled medical home health services. Therefore, if you or your loved one needs skilled medical home health care services like the ones mentioned above, coverage is possible if you can demonstrate certain things. 

First, you need to show Medicare that the care is medically necessary, which means your doctor must prescribe home care to you and provide a home care plan.  

Second, you must demonstrate that you or your loved one are homebound or that it is extremely challenging for you to receive care in a traditional medical setting, such as a hospital or doctor’s office. Often, this need is shown by having a mobility challenge. 

Next, you must show that you need one or more of the following services on an intermittent basis: skilled nursing care, speech-language therapy, physical therapy, or occupational therapy. The term intermittent is subjective and is often the source of confusion for many people. However, generally, it means that care is not needed 24-7, 365-days per year. Or, if someone needs round-the-clock care, it can only be necessary for 21 days or less, for example, after major surgery. Therefore, if you or a loved one needs care on more than a part-time basis, you’re only eligible for this skilled medical home health care benefit for a short period of time. Therefore, if you or your loved one needs care on a full-time basis, you would need to contact a non-medical home care provider to cover the long-term care needs.

Overall, it is important to note that Original Medicare does not cover non-medical home care services. Therefore, if you anticipate that you may need that type of help, you may be better off looking at Medicare Advantage, which we describe in detail below. 

Medicare Advantage and Private Pay: Best for Non-Medical Home Care Services 

As mentioned above, the Original Medicare plan will provide coverage for skilled home health care that is medically necessary, but are there options for those who want non-medical home care services? The short and sweet answer is yes. Fortunately, Medicare Part C, also known as Medicare Advantage, is an option for you if you’re looking for a way to pay for your non-medical home health care needs. 

How Medicare Advantage Works

Medicare Advantage is a supplemental health plan for those who require additional services not covered by Original Medicare. Unlike Original Medicare, which is sponsored by the federal government, Medicare Part C plans are sold through independent insurance companies. As a result, these insurance companies can offer different benefits and coverage. Still, they are required by law to provide at least the same benefits as Plan A and Plan B. Fortunately, there are a few that currently cover non-medical home care services as well. However, because there are different plans, you have to shop around to find a Medicare Advantage plan that works for you. In addition, you have to make sure you’re eligible. 

To access Medicare Advantage plans, you must meet two general eligibility requirements which are: 

  1. You or your loved one must be enrolled in Original Medicare (Plan A and Plan B) and 
  2. You must live in a service area that includes a Medicare Advantage insurance provider that’s allowing new users during your application period. 

Does Medicare Advantage Cost? 

Medicare Advantage may require a monthly premium, but currently, 60% of people are enrolled in a $0 premium plan. If you have to pay a premium, the average cost for a Medicare Part C plan is $60.96 per month. There is also a limit on how much you have to pay out-of-pocket annually for Medicare coinsurance, deductibles, and more. 

Which Home Care Services Are Covered by Medicare Advantage? 

Now that you know that Medicare is an option for non-medical home care services, you probably want to know what exactly is covered. Although the benefits covered depend on the Medicare Advantage plan you have, most of the plans cover the following non-medical home care services: 

  • Assistance with certain activities of daily (ADLs) such as feeding, bathing, dressing, transferring, toileting, etc.
  • Assistance with some instrumental activities of daily living (IADLs) like laundry, grocery shopping, errands, meal preparation, etc.
  • Providing transportation to doctor’s appointments 
  • Respite care
  • And more

What If I Don’t Have a Home Care Benefit In My Medicare Advantage Plan? 

You may feel frustrated or helpless if you suddenly realize that your Medicare Advantage plan does not cover necessary home care benefits. You may worry: How will I receive the non-medical home care services I need? The good news is that even without Medicare Advantage, there are other options to pay for non-medical home care. One of these is to cover your home care services out-of-pocket.

Although this may not be an option for some Americans, there are several benefits to going this route. Paying out-of-pocket allows the care seeker to shop around with more non-medical home care providers, expands access to more caregivers, and generally gives the individual more freedom and options to consider. Instead of being confined to the limitations of Medicare Advantage Plans, individuals can choose from various agencies and expand the scope of services needed. Many of these agencies will work with your budget to ensure any financial concerns are addressed. Paying privately with agencies usually comes with bonded and insured caregivers, workers’ compensation benefits, and more, giving you peace of mind that the caregivers you are paying for are vetted, trained, and supported. Essentially, paying out-of-pocket gives you more flexibility in what you can do and ask for, making this a better option for those who do not have Medicare Advantage Plans or who have unique needs.

Another option could be seeing if long-term care insurance is an option for you or your loved ones.

Consider Long-Term Care Insurance

Long-term care insurance, or LTCI for short, is an important and useful insurance product. Unfortunately, however, it’s one that many consumers aren’t aware of. LTCI is coverage purchased before you or your loved one becomes sick or disabled. After insurance is purchased, and if you have a qualifying incident, like a stroke, the long-term insurance will kick in and pay for at least a portion of the home care costs. 

Although long-term care insurance is not for everyone, it can be a great option for someone who needs a little bit more of a safety net. When you consider that almost 70% of individuals over 65 will need some form of long-term care and that many of those individuals will want to age in place, LTCI seems like an attractive option. However, it’s important to also note that many home care organizations that accept LTCI often require individuals to put their own money down first and then later get reimbursed by their insurance. Fortunately, at 24 Hour Home Care, we make billing simple by billing the insurance directly, which means no out-of-pocket costs for patients and their family members. 

Non-Medical Home Care Can Make Better Health a Reality 

From a young age, we’ve been conditioned to believe that health care happens in hospitals and doctor’s offices. But, the reality is that care can occur in any setting in which trained professionals interact with individuals who have distinct needs. Medicare understands this and has programs in place to reimburse care delivered in the home setting, helping make home care more accessible.

The information above provides some of the important basics about how Medicare coverage works for home care. However, if you or your loved one wants to see what non-medical home care options are available to you, contact 24 Hour Home Care today. Our team of specialists can guide you on what this process looks like for you and your loved ones.

More like this