Home Care Payers
Medicare is health insurance for the following:
- People 65 or older
- People under 65 with certain disabilities
- People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)
The Different Parts of Medicare
Medicare Part A (Hospital Insurance)
- Helps cover inpatient care in hospitals
- Helps cover skilled nursing facility, hospice, and home health care
Medicare Part B (Medical Insurance)
- Helps cover doctors' services, hospital outpatient care, and home health care
- Helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse
Medicare Part D (Medicare Prescription Drug Coverage)
- A prescription drug option run by Medicare-approved private insurance companies
- Helps cover the cost of prescription drugs
- May help lower your prescription drug costs and help protect against higher costs in the future
Medicare Advantage Plans (like an HMO or PPO) are health plans run by Medicare approved private insurance companies. Medicare Advantage Plans (also called "Part C") include Part A, Part B, and usually other coverage like Medicare prescription drug coverage (Part D), sometimes for an extra cost.
Medicare and Home Health Services
Medicare pays for you to get certain health care services in your home if you meet certain eligibility criteria and if the services are considered reasonable and necessary for the treatment of your illness or injury. This is known as the Medicare home health benefit.
If you get your Medicare benefits through a Medicare health plan (not Original Medicare) check your plan's membership materials, and contact the plan for details about how the plan provides your Medicare-covered home health benefits.
If you have Medicare, you can use your home health benefits if you meet all the following conditions:
- You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.
- You must need, and a doctor must certify that you need, one or more of the following.
- Intermittent skilled nursing care
- Physical therapy
- Speech-language pathology services
- Occupational therapy
- The home health agency caring for you must be approved by Medicare (Medicare certified).
- You must be homebound, and a doctor must certify that you're homebound. To be homebound means the following:
- Leaving your home isn't recommended because of your condition.
- Your condition keeps you from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person).
- Leaving home takes a considerable and taxing effort.
A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as attending religious services. You can still get home health care if you attend adult day care, but you would get the home care services in your home.
To view or print a copy of the "Medicare & You" handbook, visit http://go.usa.gov/iDJ.
You can also call 1-800-MEDICARE (1-800-633-4227) if you have questions about your Medicare benefits. TTY users should call 1-877-486-2048.
Medicare and Long-term Care
While there are a variety of ways to pay for long-term care, it is important to think ahead about how you will fund the care you get. Generally, Medicare doesn't pay for long-term care. Medicare pays only for medically necessary skilled nursing facility or home health care. However, you must meet certain conditions for Medicare to pay for these types of care. Most long-term care is to assist people with support services such as activities of daily living like dressing, bathing, and using the bathroom. Medicare doesn't pay for this type of care called "custodial care". Custodial care (non-skilled care) is care that helps you with activities of daily living. It may also include care that most people do for themselves, for example, diabetes monitoring. Some Medicare Advantage Plans (formerly Medicare + Choice) may offer limited skilled nursing facility and home care (skilled care) coverage if the care is medically necessary. You may have to pay some of the costs.