The government, however, has set some limitations on payouts - you are
only eligible if you need intermittent care (usually defined as seven
days a week or less than eight hours a day over 21 days or less) (1),
physical/occupational therapy or speech language pathology; you are
homebound; and the home health care agency providing care is approved
by your Medicare insurance program.
In addition to medication administration, general supervision, and
therapy services, the Medicare home health benefit covers a number of
other necessities, including medical aids and supplies to aid in
recuperation. On the occasion, though, you may be required to cover
some of the costs associated with home health care. But what can you
expect to pay out-of-pocket that's not covered by Medicare dollars?
Medicare Insurance: Part A and Part B
Hospital Insurance (Medicare Part A) helps cover the costs of your
inpatient care at hospitals, skilled nursing facilities, or religious
non-medical health care establishments. Part A can also help cover
hospice and home health care services. Individuals aged 65 and older
are usually automatically enrolled in Medicare Part A and do not have
to pay a monthly premium if Medicare taxes were paid while working. If
you did not pay taxes, you are still eligible, but you will be
required to pay a monthly premium.
Medical Insurance (Medicare Part B) helps cover services such as those
offered by your physician and outpatient care. Many seniors maintain
their enrollment in Part A, but elect not to use Part B, which
requires a monthly premium that is dependent upon income, the
requirements of which change yearly. Unfortunately, if you didn't sign
up for Part B when you were first eligible for insurance, your premium
may be slightly higher (2).
For questions on your Medicare insurance benefits, you should contact
1-800-MEDICARE or read the handbook mailed to you each year entitled
"Medicare and You."
What's Covered and What's Not
Medicare insurance pays for physical and occupational therapy and
speech language pathology services, counseling, some medical supplies,
durable medical equipment (which must meet coverage criteria), as well
as general assistance with daily activities which include dressing,
bathing, eating, and toileting. For most other medical equipment,
Medicare insurance will cover 80% of its cost (3).
However, Medicare will not cover twenty-four hour care at home, meals
delivered to your home, and services unrelated to your care such as
housekeeping. Of course, as mentioned above, you will be required to
pay 20% for medical equipment not fully covered by Medicare insurance
such as wheelchairs, walkers, and oxygen tanks (4).
In some cases, your home health care agency may present you with a
Home Health Advance Beneficiary Notice (HHABN), which, simply put,
means if your agency is ceasing your care services, you will be
presented with a written statement outlining the supplies and services
the agency believes your Medicare insurance benefits will not cover as
well as a detailed explanation of why. Should this situation arise,
you do have recourse - the HHABN lists directions on acquiring the
final decision on payment issues or filing an appeal if Medicare
refuses to cover costs for home health care. In the meantime, you
should continue receiving home health care services, but keep in mind
that you will be paying for these services out-of-pocket until
Medicare accepts your claims and remits past expenses.
Medigap and Other Out-of-Pocket Expenses
Medigap, a supplemental insurance policy, is sold privately and covers
the services and supplies not paid for by Medicare insurance. When
used in conjunction, Medigap and Medicare can often cover a large
majority of the costs of your home health care. Insurance companies
offer a variety of different Medigap policies (A through L), but since
each one comes with specific benefits, you'll need to compare the
highlights closely. Medigap policies vary by cost, and many insurance
companies require you to have both Medicare Parts A and B in order to
purchase a supplemental plan (5).
For seniors with both Part A and Part B Medicare, your home health
care situation is usually covered, save for the 20% out-of-pocket
expenses for medical equipment. Just remember to keep track of your
Medicare insurance benefits (and Medigap if applicable) by verifying
with your physician, home health care agency, and insurance
representative. Paying for home health care does not have to cost you
an arm and a leg, but do be prepared for the occasional (but
necessary) out-of-pocket medical expenses.
1. Centers for Medicare and Medicaid Services, Medicare and Home
Health Care, page 6
About the Author:
Jill Gilbert is the President and CEO of
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