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Home Health Care & Medicare Coverage: What to Know

Home Health Care & Medicare Coverage: What to Know

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We all know Medicare doesn’t cover a long-term care stay. But what about home health care?

While home health care is a great way to get long-term care in the comfort of your own home, the costs can be confusing.

Medicare does offer some coverage for home health care, but there are limitations and exclusions. In this article, we’re unpacking the real costs of home health care and what you can expect Medicare to pick up or leave behind.

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Why Home Health Care?

Recently, there’s been a preference shift from traditional nursing home care to home and community-based care. For the first time in 2015, more money was spent on home health care than nursing home care (CNBC).

Having a nurse or caregiver come and provide care at home solves a lot of unique problems:

  • It relieves your loved ones and family from being an around-the-clock caregiver
  • It allows you to stay in the comfort of your own home
  • You can get skilled nursing care from certified, licensed nurses who are uniquely trained to meet complex medical needs
  • Patient outcomes are comparable or even better when care is received at home, thanks to the social interaction and one-on-one support (Bayada)

According to Senior Living, many seniors report a better quality of life and general happiness with in-home care, and some studies even show a 50% reduction in annual doctor visits.

The home health care industry is growing at a rapid pace of seven times faster than the rest of the economy. This is partly because people want to stay home, understandably, but also because the Baby Boomer population is aging, and the demand for care in general is increasing.

We know there’s a 70% chance you’ll need some form of long-term care in your life after the age of 65 (U.S. Department of Health & Human Services). If you think you’d prefer home care, it’s time to understand your costs so you can prepare.

Home Health Care Costs

The cost of home health care varies based on a few things:

  • How much care you need – from just a few hours a day to 24/7 care
  • How much skilled care you need – do you need a basic home caregiver or a medical professional, such as a nurse, physical therapist, or licensed physician?

If you personally hired a basic home caregiver to come for 20 hours per week at $15 per hour, your costs would be just $300 per week. There are several senior caregivers in the Decatur, IL who charge anywhere from $15-$25/hr (Care.com).

On the other hand, if you got skilled care through a home care agency and needed 40-44 hours of care per week, your costs would be more like $250 per day, or $1,750 for a full week of home care.

For context, a private room in a nursing home costs, on average, $1,850 per week.

Part of the appeal of home health care, aside from staying in the comfort of your own home, is flexibility. It can also be significantly less expensive than a nursing home, but that’s not necessarily the case if you need 24/7 care.

Medicare & Home Health Care

Medicare’s coverage of home health care is very limited.

First, the skilled home care must be part-time or intermittent. Medicare defines this as less than 7 days each week or less than 8 hours per day over a period of 21 days or less.

It’s important to know that Medicare will never pay for 24/7 home care.

In addition, Medicare won’t offer any coverage for home care if you only need help with custodial or personal care, such as bathing, dressing, or using the bathroom (often referred to as the Activities of Daily Living, or ADLs).

Typically, people need long-term care services because they need help with the Activities of Daily Living, so it’s critical to understand that Medicare does not offer home care coverage for help with ADLs (if that’s all you need).

So… when does Medicare offer coverage for home care?

You’re only eligible for Medicare home care coverage if you meet all the following conditions (yes, all of them):

  • You’re under the care of a doctor who created and regularly reviews your plan of care.
  • A doctor certifies that you need intermittent skilled nursing care (other than drawing blood).
  • A doctor certifies that you need physical therapy, speech-language pathology, or continued occupational therapy services.*
  • The home health agency caring for you is approved by Medicare (Medicare certified).
  • A doctor certifies that you are homebound.

*These services are covered only when the services are specific, safe and an effective treatment for your condition. The amount, frequency and time period of the services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively. To be eligible, either: 1) your condition must be expected to improve in a reasonable and generally predictable period of time, or 2) you need a skilled therapist to safely and effectively make a maintenance program for your condition, or 3) you need a skilled therapist to safely and effectively do maintenance therapy for your condition.

If you meet all of those requirements, you would pay $0 for home health care services and 20% of the Medicare-approved amount for durable medical equipment (walker, wheelchair, hospital bed).

If you have a Medicare Supplement, the 20% coinsurance for durable medical equipment would be covered, so your costs would be $0.

Verifying Your Home Care Costs

Because the Medicare requirements are so strict and limited for home care coverage, you should talk to the home health agency and ask how much Medicare will pay.

That agency should also tell you if any items or services they give you aren’t covered by Medicare, as well as how much you will have to pay for them.

All home health agencies should give you an Advance Beneficiary Notice (ABN) before they give you any services or supplies that Medicare won’t cover.

How to Find Medicare-Certified Home Care Agencies

If you meet all of the eligibility requirements for Medicare home care coverage, you still have to find and use an agency that’s Medicare-certified.

Use Medicare’s new Care Compare tool to find certified home health care agencies near you.

Just type in your zip code and you’ll see a list of options.

In zip code 62526, there are 10 home health agencies that are Medicare-certified:

  1. Advanced Healthcare Services, LLC
  1. Alterna Care Inc.
  1. Community Homecare, Inc
  1. Decatur Memorial Hospital Home Health Services
  1. Elara Caring V
  1. Encompass Health Home Health
  1. Lhc-Illinois Home Health Care
  1. St. Johns Hospital Home Health
  1. Vital Wellness Healthcare, Inc
  1. Whitestar Home health Inc

If you decide to use an agency that isn’t Medicare certified, Medicare will not provide any coverage.

Also, if you hire a basic caregiver on your own – such as someone you find on Care.com – all of your home care costs would be your responsibility.

Home Care Insurance Options

Because Medicare coverage of home care is so limited, many individuals look at purchasing an insurance policy specifically for home health care.

It’s much more affordable than a traditional long-term care policy, because the benefit period is typically shorter, and home care is generally less expensive than a nursing home stay.

We offer short-term care insurance plans from companies like Aetna, Guarantee Trust Life (GTL), and Standard Life. Many short-term care plans include home health care coverage.

In fact, GTL even has a short-term care insurance product that’s specifically designed to help you pay for daily home care services. With premiums starting at less than $20 per month, it’s worth considering.  

GTL’s plans even come with access to online symptom assessment services by Mayo Clinic.

Conclusion

The chances of needing some kind of extended care in your lifetime are high – around 70% of people over age 65 will need long-term care at some point.

If you think you’d prefer to age in place, ensure you understand the costs of home care and are financially prepared. Medicare’s coverage of home care is very limited, but there are home care insurance options that are affordable and offer peace of mind.

Talk to an agent today to get a free quote on a home care plan. You can call our office at 217-423-8000 or schedule an appointment online.

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