Knowing what Medicare Covers

Proper planning starts with a basic understanding of the insurance system

If you are navigating the seas of home care for the first time, you may be wondering, “doesn’t Medicare pay for help in the home?” Before answering that question, you should understand the difference between Home Health and private-duty, in-home care. Home Health care is medically focused while private-duty care usually focuses on non-medical care, such as bathing, dressing, meal preparation, and light housekeeping. Some states, however, allow private-duty nursing (like wound care, injections, and venipuncture) as well. Each Always There office can tell you about the laws in their state. The other big difference between Home Health and private-duty care is the payer source – who pays the bill. Home Health can be covered by traditional health insurance and Medicare. Private-duty care is usually paid by the client, or by a long-term care insurance company, if the client has that kind of policy.

Most people would like to take advantage of an insurance benefit, if possible. People covered under traditional health insurance policies should contact their local plan administrator to determine if they have home care coverage. For Medicare recipients, the information below may be helpful in learning about the home health benefit.

In the most general terms, home health care is medically oriented (meaning nursing or therapy), short-term care provided to a home-bound individual. Clients who need assistance only with bathing, dressing, or meal preparation are NOT eligible for any Medicare-covered home health care. These are considered “custodial” tasks and not medical tasks.

The table below demonstrates some of the key differences between Medicare’s home health coverage and the in-home services provided by Always There.

Home Health Care
1. Paid by Medicare
2. Must be prescribed by a doctor
3. Triggered only by a need for skilled nursing, physical therapy, speech/language therapy, or occupational therapy
4. Client must be “homebound”*
5. Care is intermittent and short term
6. Assistance only with a bath not covered
7. Duration of visit by nurse or aide usually less than one hour
8. No coverage for housekeeping or errands
Private-Duty Home Care
1. Paid out-of-pocket or by long-term care insurance
2. Does not need to be prescribed by a doctor
3. Requires no trigger. Client can hire private-duty home care whenever he/she desires
4. No such restrictions
5. Care can endure as long as client requests
6. Assistance only with a bath is available
7. Duration of visit usually 4 hours or longer
8. Caregivers may perform housekeeping and assist with errands

What does “homebound” mean? According to the Centers for Medicare and Medicaid, a person is defined as homebound if they are, “normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort.” Therefore, if a person is extremely short of breath and must rest every few feet while walking, he/she would probably be considered homebound. Furthermore, the Medicare rules state that a person may still be considered homebound even if they do leave the home for… “short, infrequent trips for non-medical reasons, such as a trip to the barber or to attend religious services. However, if a person leaves the home more than once a week, he/she is NOT considered homebound and will not be eligible for Medicare-covered home health care.

If you think you may be eligible for services that would be covered by Medicare, you should call your physician who can refer you to a reputable home health agency.

Medicare’s coverage of home health care is very different from private-duty home care, but the two often compliment each other. Sometimes Always There works independently in a client’s home, and sometimes we work in conjunction with a home health agency. The following is an example of a typical situation where a client may use both Always There In-Home Care and a Medicare-covered Home Health Agency.

Mrs. Smith was discharged from the hospital after a long illness. She lives with her husband. The ABC Home Health agency has been asked to send a physical therapist to her home twice a week and a home health aide from the same agency three  times a week. The aide will give Mrs. Smith a bath.

The Smiths think they need more help. They hire Always There. It is determined at the initial assessment that our caregiver will be at the Smith’s home Monday through Friday from 9 a.m. until 4 p.m. The Smiths’ daughter stays with them on the weekends.

The ABC agency therapist tells Mr. and Mrs. Smith that she will visit on Tuesdays and Thursdays and she’ll “probably” be there about 10 a.m. Some days she does not arrive until noon. She usually stays about 30 minutes. The aide comes Monday, Wednesday and Friday. Mr. and Mrs. Smith are never sure what time she will arrive. She stays about 40 minutes when she comes. On the other hand, the Always There caregiver arrives promptly at 9 a.m. every morning and stays until 4 p.m. every day. She is busy helping the Smiths at all times.

On Mondays, Wednesdays, and Fridays, the ABC aide gives Mrs. Smith a bath while the Always There caregiver performs other household duties, such as laundry, vacuuming and meal preparation. But Tuesdays and Thursdays, the Always There caregiver assists with the bath. On the days the therapist visits, the Always There caregiver watches and helps with the therapy session. When the therapist discontinues her home visits, the Always There caregiver can help Mrs. Smith continue to practice her exercises. Long after the ABC agency has discontinued their services, Always There remains in the home and continues service to Mr. and Mrs. Smith.

Posted on Wednesday, July 22nd, 2009 :: Filed under Articles.