If you or your loved one is like most adults age sixty-five and older, they probably enjoy Medicare coverage. In order to qualify for this national health insurance program, you must have worked for a certain length of time, known as “quarters,” and paid into the health care system. There are exceptions, such as younger people with disabilities or individuals with end-stage renal disease. These individuals may qualify without meeting the work mandate. However, for the most part, Medicare is the health insurance of choice for elderly adults in the United States.
Unfortunately, myths abound regarding what Medicare covers and what it does not. If you’re considering health services at home, it’s important to know exactly what coverage includes. Otherwise, you or your loved one could be looking at a hefty, unexpected bill that you may not be able to afford.
Skilled home care
The good news is that Medicare coverage includes one of the most expensive and common services seniors need: skilled care at home. These services fall under Medicare Part B: the medical insurance portion (Part A is for hospital services). Skilled home care includes things like nursing (IV infusion, wound dressing, et cetera), physical, occupational, speech therapy, and social services.
These are services that only someone with a high level of education and training can perform, such as a licensed professional. However, Medicare only covers such services on an intermittent or short-term basis. In other words, Medicare will not continue to pay for them long-term or indefinitely.
Besides the age requirement, there are other criteria you must meet in order to be considered eligible for skilled services under Medicare. First, the services must be ordered by a physician and you must be under a plan of care that is regularly reviewed by him or her. Second, you must receive the services from a Medicare-certified home health agency (who will usually coordinate them for you with your doctor). Finally, you must be considered “homebound,” although you can still leave your home to attend adult day care, as well as certain non-medical functions, such as religious services.
These aren’t the only conditions that apply when it comes to Medicare coverage of skilled services; be sure to check with your provider about your portion of the payment responsibilities.
Now for the not-so-good news: unfortunately, Medicare doesn’t cover another common need the elderly have: custodial care. Custodial care includes non-medical services, such as assistance with ADL’s (Activities of Daily Living), such as bathing, feeding, visiting the restroom, and the like. Custodial care can also consist of things like help with meals or housekeeping – even if the senior is physically or mentally incapable of doing these things themselves.
Because this type of care can be performed by someone with a lesser degree of training (like a certified home health aide as opposed to a licensed nurse), it’s not considered a medical necessity. This means that if you or your elderly loved one has a specific physical condition, general frailty, or mental incapacity that precludes self-care, you may have to look into other coverage options.
Options besides Medicare coverage
All isn’t lost if you or your family member has custodial needs, but lacks the private funds to pay for them. Medicaid, another federally-funded health insurance program, will pay for custodial care for the elderly at home. Again, certain criterion needs to be met in order to qualify for a) Medicaid, and b) the home care portion, so remember to check with your provider. There are also private insurance options that may reduce the cost of custodial care, but this differs with the individual company.
A good home health agency can explain your options
A qualified home health agency is experienced in the various coverage options when it comes to skilled versus custodial care. Talk to one today to see how you or your loved one’s needs can be funded. This way, you can shift the focus from worrying about medical bills to functioning well and feeling your best!
If you are unsure of how to best help an aging loved one, the trained and compassionate staff at the Institute on Aging is here to help you make that decision and gain the best in at-home senior care. Contact us to find out more.