3 Things to Know About Medicare and Home Health Care

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Home health care. It may not necessarily be something you want (or even want to think about). But when surgery or an illness keeps you from being able to care for yourself, it is something you may need.

Medicare might help, but it's best to understand what Medicare covers for home health care services, so you can make the best decisions for your health when you need it.

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1. Medicare's definition of "home health care"

The first step to getting Medicare coverage for a home health care service is to understand the true definition of home health care.

"People often get confused as to what home health care is versus what home care is. For something to be considered home health care, there has to be a health need that must be provided by a skilled person, such as a nurse, physical therapist, or occupation therapist," says Betsy Farrell, RN, BS, MHA, and director of performance management at Aetna. "Home care, rather, could involve an aide coming to your home and helping you bathe or cook. This kind of care in the home is not covered by Medicare."

If you're looking to get certain home health care services covered by your Medicare plan, you'll want to make sure they're considered home health care services, and not general home care services.

2. The home health care services Medicare will (and will not) cover

All Medicare Advantage plans must provide at least the same level of home health care coverage as Original Medicare (Parts A and B). Eligible home health care services like the following both under Original Medicare and any Medicare Advantage plan:

  • Part-time or intermittent skilled nursing care (such as wound care for pressure sores, patient and caregiver education, intravenous or nutrition therapy, injections, monitoring serious illness and unstable health status)
  • Physical therapy
  • Occupational therapy
  • Speech-language pathology services
  • Medical social services

In order to be eligible for these home health care services, you must be under the care of your doctor and be getting services under a care plan created and reviewed regularly by them. Your doctor must also certify that you're homebound.

Original Medicare and Medicare Advantage plans won't pay for:

  • 24-hours-a-day care at home
  • Custodial or personal care when this is the only care you need
  • Homemaker services (such as shopping, cleaning, and laundry) when this is the only care you need, and when these services aren't related to your care plan

3. Your Medicare plan's policy

The coverage, costs, rules, and restrictions for home health care services will vary based on your plan. That's why it's important to view your plan's Evidence of Coverage (EOC) to understand your specific coverage.

The plan's EOC will explain the details of what's covered for home health care and let you know whether or not you're qualified to receive home health care. Farrell says it's important to know that if you don't qualify for home health care coverage, it may be because you need a bit more care than what home health care can offer.

"You may first go to a skilled nursing facility so you can safely transition from an inpatient setting, like the hospital, to your home. This happens when your condition is not acute enough to need 24-hour care at a hospital, but you're also not ready to be completely home even with home health care," she says.

At the end of the day, the coverage you'll get for home health care depends on a lot of factors. To get a full understanding of what you qualify for, you'll want to talk to your doctor and call your plan.

Rachel Quetti is a health care writer at Aetna with experience in senior wellness, Medicare, commercial health care, and consumer engagement. When Rachel isn't trying out new fitness classes, she is cooking up fun, (mostly) healthy recipes in the kitchen. Rachel lives in Watertown, Massachusetts and has a degree in journalism from the University of Massachusetts, Amherst.